Acta Otorrinolaringol Esp.

2016;67(4):187---192

www.elsevier.es/otorrino

ORIGINAL ARTICLE

The Efcacy of Individual Treatment of Subjective

Tinnitus With Cognitive Behavioural Therapy
Pascual Canals,a, Beln Prez del Valle,b Francisco Lopez,a Amparo Marcoa

a
Servicio ORL, Hospital de Sagunto, Sagunto, Valencia, Spain
b
Servicio ORL, Hospital Clnico Universitario de Valencia, Valencia, Spain

Received 18 January 2015; accepted 6 May 2015

KEYWORDS Abstract
Subjective tinnitus; Introduction: It has been a long time since subjective tinnitus cases were described for the rst
Psychologist time but they still lack a treatment with proven effectiveness. The main goal of this study was
interview; to evaluate the effectiveness of cognitive behavioural therapy in these patients.
Cognitive behavioural Patients and method: Between 2012 and 2013, 310 patients that suffered from subjective tinn-
therapy itus were studied. Of these, 267 were included in treatment based on cognitive behavioural
therapy. The monitoring period lasted 18 months for most cases, while it lasted 21 months for
11 patients.
Results: Considering patients that interrupted their treatment as failures, the percentage of
recovery was 95.7%.
Conclusion: Cognitive behavioural therapy should always be included in the treatment of people
suffering from tinnitus.
2015 Elsevier Espa na, S.L.U. and Sociedad Espa nola de Otorrinolaringologa y Ciruga de
Cabeza y Cuello. All rights reserved.

PALABRAS CLAVE La ecacia del tratamiento individual de los acfenos subjetivos con terapia
Acfenos subjetivos; cognitiva-conductual
Entrevista
psicolgica; Resumen
Terapia Introduccin: Los acfenos subjetivos, a pesar del tiempo transcurrido desde que fueron
cognitiva-conductual descritos por primera vez, continan sin tener un tratamiento con ecacia demostrada. El obje-
tivo de este artculo es valorar la ecacia de la terapia cognitiva-conductual en el tratamiento
de estos enfermos.

Please cite this article as: Canals P, Prez del Valle B, Lopez F, Marco A. La ecacia del tratamiento individual de los acfenos subjetivos
con terapia cognitiva-conductual. Acta Otorrinolaringol Esp. 2016;67:187---192.
Corresponding author.

E-mail address: canals pas@gva.es (P. Canals).

2173-5735/ 2015 Elsevier Espa

na, S.L.U. and Sociedad Espa
nola de Otorrinolaringologa y Ciruga de Cabeza y Cuello. All rights reserved.
188 P. Canals et al.

Pacientes y mtodos: Durante un periodo de tiempo de los a nos 2012-2013 se estudia a 310
enfermos que presentaban acfenos subjetivos. De ellos, 267 fueron incluidos en un tratamiento
basado en terapia cognitiva-conductual. El periodo de seguimiento fue de 18 meses y en 11
enfermos de 21 meses.
Resultados: Considerando los enfermos que interrumpieron el tratamiento como fracasos, el
porcentaje de curacin fue de 95,7%
Conclusin: La terapia cognitiva-conductual debe estar siempre incluida en el tratamiento de
los enfermos de acfenos.
2015 Elsevier Espana, S.L.U. y Sociedad Espa
nola de Otorrinolaringologa y Ciruga de Cabeza
y Cuello. Todos los derechos reservados.

Introduction Numerous studies have been undertaken to nd the most

benecial treatment but none have yet been conclusively
Much has been written about the treatment of tinnitus over demonstrated. Only cognitive-behavioural therapy seems to
many centuries. One of the most important medical (not be reasonably established in meta-analysis studies.
surgical) documents is Ebers papyrus, dating from the 18th Some authors advocate the use of hearing aids, maskers
dynasty (16th century BC), which mentions some of the most and retraining therapies, although results are mixed.5
ancient of treatments. Paragraph 678 refers to bewitched Back in 1995, we suggested that the collaboration of a
ear, which presumably means the treatment of tinnitus, psychologist was necessary, sometimes even a psychiatrist,
and describes an infusion based on desert date oil, incense together with the ENT specialist to establish the correct
and 2 other unknown ingredients, and put into the ear. treatment for tinnitus.6
Several authors have attributed the rst reference to
masking to Hippocrates: why is it that ringing in your ears
stops if somebody makes a noise? Is it because a louder noise Material and Methods
cancels out a less intense one?1
Jean Marie Gaspard Itard (1775---1838) defended the use The study was performed with a sample of 310 patients over
of a clockwork motor to mask tinnitus. For cases of untreat- a period of 2 years (from January 2012 to December 2013);
able tinnitus he suggested that patients could only achieve 120 female and 190 male patients (Fig. 1). The patients were
sustained relief if they were to live in a watermill.2 aged from 23 to 84; the majority of the sample was aged
John Harrison Curtis (1778---1860) was the rst to recog- between 40 and 70 (Fig. 2).
nise the psychological aspects of tinnitus and often defended The patients came from our Health Area as well as
the use of psychological cures and relaxation therapies.3 the rest of the country, referred by the Spanish Tinnitus
Masking, as upheld by Itard, fell into oblivion until the
end of the 19th century and was revisited by Spalding in
1903. Jones and Knudsen provided more technological bal- 0
ance with their harmonic generator in 1928.4
Itards conclusion almost 2 centuries ago, that treatment
for tinnitus generally fails and that doctors should focus
on relieving its difcult symptoms, still stands. There were
no serious medical/psychological considerations on the sub-
ject. Fowler looked at such aspects 66 years ago (1948), and
as a result there have been a great many alternative treat-
120
ments in recent years, from Chinese traditional medicine
such as acupuncture, to moxibustion, yoga, etc.
The development of electronic technology introduced 190
other masking techniques: electrical stimulation, transcra-
nial magnetic stimulation, direct stimulation of Heschls
gyrus and, nally, there is mention of the benecial effects
of cochlear implants.
There are also treatments which correct comorbidi-
ties such as depression and anxiety: behavioural therapies,
biofeedback, cognitive-behavioural therapy, etc.
Medication includes: topical lidocaine, benzodiazepines,
intratympanic dexamethasone, ginkgo biloba, melatonin, Figure 1 Graphic representation of patients by gender (120
zinc, niacin, calcium antagonists, etc. females and 190 males).
The Efcacy of Individual Treatment of Subjective Tinnitus
90 86
82 81
80
70
60
50
40
30 27
21
20
10
10
0 how severe their tinnitus is at the present time.
20-30 31-40 41-50 51-60 61-70 71-80
Ages
Figure 2 Graphic representation by age.
Association. All of the patients were visited in public health-
care hospitals.
The methodology used was based on cognitive
behavioural theory. The psychological basis behind this
theory is that by changing a persons thinking, we can
change their belief system and this will then result in
changes in their behaviour.
We started with an ENT examination of the patient to
rule out any organic cause and conrm that the tinnitus was
subjective in origin.
When the tinnitus was unilateral, we always requested
magnetic resonance imaging to rule out inner ear disease.
All the patients underwent audiometry and acufenome-
try, the latter was standardised in 1981 by a panel of experts
in the symposium of the Ciba Foundation.7
We take the severity of patients symptoms very seri-
ously, and their effect on their mental health. It is important
to measure the psychological impact of tinnitus and how
debilitating it is for patients.
To this end, the most accepted test in the medical liter-
ature in English is that proposed by Newman and Jacobson8 :
the Tinnitus Handicap Inventory or THI. We use the Spanish
version of Herraiz et al.,9 translated from the English and
adapted into the Spanish language.
We also used the 5 levels of severity grading as proposed
by McCombe.10
We consider that a psychological assessment of the
patient is very relevant towards nding a solution and in
planning treatment. We use Becks anxiety and depression
inventories for this assessment. We also use Holmes inven-
tory to measure the patients exposure to stress and the
probability of psychosomatic disease in the cases where this
might offer us valid information.
For patients with hearing loss we used the test for hyper-
sensitivity to sound adapted to Spanish by Herraiz.11
Of the 310 patients who started treatment based on the
information provided by the battery of tests, we excluded
those with a THI score lower than 16, (14 patients in total),
those who only suffered tinnitus in silent atmospheres and
those who were not distressed by it. Three further patients
with objective tinnitus were added to the 14; these 17
patients made up subgroup E (excluded patients) and con-
stituted 5%.
189
Another subgroup, which we called P, was made up
of all the patients with serious psychotic symptoms who
were undergoing psychiatric treatment and for whom it was
impossible to use the therapy. There were a total of 18
patients in this group (16%). After the patients in subgroups
E and P were rejected, our study comprised a population of
275 patients.
There was a subgroup amongst these 275 patients
which we shall call IT (interrupted treatment) compris-
ing 8 patients, of whom 3 had severe (THI=58---76) and 5
catastrophically severe tinnitus (THI=78---100). We consid-
ered that the treatment failed in these 8 patients (2.8%), 5
3 of whom came from other regions, although we do not know
81-90
The patients visited every 3 months and at each visit we
repeated the THI. From the information obtained from the
second THI, and the level of distress caused by the tinnitus
at that time, in this second session we compared the score
with that of the previous session. If the difference was a
decrease of more than 20 points compared to the rst test,
this indicated to us that the therapeutic interview had been
effective and that the patient had taken an active approach
to their problem, and therefore we could predict that their
tinnitus would become less troublesome.
We completed a maximum of 6 therapeutic interviews;
if the tinnitus was still problematic for the patients and
in addition we detected possibilities of improvement, we
prolonged the visits.
In the 267 patients who followed the treatment, we paid
particular attention to 2 parameters:
(1) A reduction in THI score by more than 20 points over a
time period of 3 months from one consultation to the
next, as a criterion for the efcacy of the treatment.
(2) The time it took to achieve a THI score of below 16
and for the tinnitus to cease to be troublesome for the
patient.
Results
When we analysed the rst point we found that at the sec-
ond consultation (at 3 months) 28% (75 patients) had a THI
score which had reduced by more than 20 points; at the
third consultation (at 6 months), 33% (86 patients); at the
fourth visit (after 9 months), 40% (91 patients); at the fth
visit (after 12 months), 52% (65 patients); at the sixth visit
(15 months), 60% (46 patients), and at the seventh visit (18
months) 90% (one patient).
In patients with a THI score below or equal to 16, which
we consider normal and therefore cured, we found the fol-
lowing results:
At the second visit, after 3 months, 2% (5 patients) had
a score that did not exceed 16. At 6 months, the third
visit, 13% (34 patients). At 9 months, fourth visit, 45%
(102 patients). At the fth visit, after 12 months, 60% (76
patients). At the sixth visit, 15 months, 80% (61 patients)
and at the seventh visit, 18 months, 96%, only one patient
had a score above 16 which, added to the 8 in subgroup IT,
made a total of 9, which means that there was 3% failure.
Figs. 3 and 4 show these data graphically.
190 P. Canals et al.

100% 90% The patients unconditional acceptance, empathy and

90%
authenticity are attributes of a therapeutic relationship
80%
which will provide an effective dimension.
Percentage

70% 60%
60% 52% The unconditional acceptance of the patient is implied
50% 40% in their response that they are going to take an active
40% 33%
30%
28% approach, since clearly they will have replied in the afrma-
20% tive to the question asking whether they want to be cured.
10% This form of awareness and strong identication with the
0%
3 6 9 12 15 18 sort of feelings produced in their interlocutor are signicant
Months to the interviewer.
Empathy involves a profoundly increased understanding
Figure 3 Reduction in THI score by more than 20 points, of the feelings of others. Some authors have highlighted the
according to the visit times. cognitive basis of this skill. However, the particular type
of comprehension implied in empathy also means engag-
120%
ing certain evaluative, perceptual and emotional aspects.
96%
100% Therefore, the interviewers empathy is demonstrated by
80%
Percentage

80%
60%
60%
45%
40%
20% 13%
2%
0%
3 6 9 12 15
Months
Figure 4 THI scores less than 16 points, according to visits.
Twenty-ve percent presented anxiety and 19% depres-
sion. There is a high correlation between the THI score and
that of Becks anxiety inventory.
Only one patient received antidepressant treatment for
30 days.
Only 5 patients were hypersensitive to sound.
Discussion
Analysis of our results clearly demonstrates the efcacy
of cognitive-behavioural therapy. These are rather higher
results than those of Hoare5 and Cima.12
Cognitive-behavioural strategies focus on thought and
behaviour processes. They are based on the premise that
in order to bring about changes in behaviour it is necessary
to change distorted thinking.
The therapeutic interview (TI) enables us to precisely
assess the psychological condition of the patient, and use it
to apply personalised treatment. The TI consists of 3 stages
or phases:
In the rst stage or phase, our psychological assessment
of the patient starts from the moment we rst meet them.
The interviews efcacy will depend very much on the doc-
tors attitude towards the patient. We must bear in mind
that these patients present special characteristics because,
generally, they have been treated by many doctors in the
past, including ENT specialists, who will have given them
negative advice such as: there is no cure for tinnitus,
tinnitus never goes and you have to learn to live with
it, and this has the effect of lowering their mood and
increasing their tinnitus perception.
Patients have been told everything that has been written
on the subject and will pay very close attention to everything
that we tell them or fail to tell them.
the way they listen, feel, perceive and respond to the
patient.
The main objective in this phase is to establish a com-
fortable relationship of rapport. We should not forget
that non- verbal communication is very important at this
stage.
18 The interview comes to an end when the patient has
provided sufcient information on their difculties.
Authenticity means that the authentic therapist behaves
in a spontaneous, non-defensive, open manner with no need
for insincerity or role playing.
We cannot lose sight of the important function that
non-verbal communication plays, since it constitutes the
foundation on which personal relationships are built.
According to various anthropologists, non-verbal communi-
cation covers all communication. We should always bear
in mind that while the patients non-verbal behaviour is
of interest, we must also be alert to the non-verbal mes-
sages that we ourselves are giving the patient, as these will
determine the extent of collaboration that we can achieve.
The second stage or intermediate phase comprises 2 sub-
stages: proposing a solution and planning treatment.
The third stage or nal phase is known as closing the
interview, and at this stage we give instructions and home-
work tasks. During this phase we stress how important it
is to follow the therapy advice once we have explained to
the patients that only 2 tools are available to us: avoiding
hearing the tinnitus and if we do hear it, not attaching any
importance to what we hear.
For the rst session and during the initial 2 sessions,
silence should be avoided since, as stated by Itard,2 listen-
ing to a loader noise will cancel out a less intense noise.
Therefore silence should be avoided and a background noise
maintained at all times even if no attention is paid to it.
We advise patients whose sleep is being disturbed by their
tinnitus, to mask it with relaxing music at sufcient volume
so that they do not hear it.
We consider that the second tool is much more important:
if you hear it, do not attach any importance to it.
This advice can carry different nuances for each indi-
vidual depending on their responses to the THI and their
general psychological prole. We illustrate these nuances
with examples of daily life, explaining how the brain often
acts in this way in different situations, choosing the stimuli
that we perceive and rejecting those that have no meaning
to us.
The Efcacy of Individual Treatment of Subjective Tinnitus
There are tests for anxiety, depression, hypersensitiv-
ity to sound and level of severity, THI, which we can
use to assess the patients psychological prole. We com-
pletely agree with several authors on the importance of this
assessment.13---15
The THI comprises 25 questions which are easy for the
patient to understand and with three response options: yes,
sometimes, no. Yes is awarded 4 points, sometimes 2, and
no points are awarded to no.
It is subdivided into 3 subscales. The functional subscale
comprises 11 items which cover the area of mental function.
The second emotional subscale comprises 9 items which
cover a wide range of emotional responses triggered by tinn-
itus. The third subscale is called the catastrophic subscale
and comprises 5 items to reect the patients desperation,
their inability to escape the problem, their perception that
it is a very serious illness, loss of control and their inability
to cope with the problem.
The scores, classied into 5 grades of severity by
McCombe,10 enable us to determine the extent to which
the patient is affected or distressed by their tinnitus: slight,
mild, moderate, severe and catastrophic.
Grade 1, slight (THI: 0---16), tinnitus only heard in quiet
environments, easily masked and almost never bothers the
patient.
Grade 2, mild (THI: 18---36), Masked by environmental
sounds and forgotten during daily activities.
Grade 3, moderate (THI: 36---56), tinnitus is noticed
despite environmental noise, although daily activities can
still be performed. However, it is troublesome at rest or in
silence and sometimes makes sleep difcult.
Grade 4, severe (THI: 58---76), tinnitus always heard, it
interferes with daily activities; leads to a disturbed rest
and sleep pattern. These patients frequently seek medical
help.
Grade 5, catastrophic (THI: 78---100), all the symptoms
are worse than the previous grade, particularly the report.
It is possible to nd associated psychiatric illness in these
cases.
It seems evident that no authors currently dispute per-
sonalised therapy. In our study, in 28% percent of cases,
the patients negative thinking about their tinnitus and its
severity was reduced after the rst interview.
The benets of other series of therapies such as mask-
ing sounds can be questioned, when the superior efcacy
of the psychological interview over masking has been
demonstrated.16 Other authors17 show that the benets of
sound therapy per se have not been proved in the treatment
of tinnitus.
Neither is there debate as to whether hearing aid ampli-
cation is of benet for tinnitus, because it masks the
environment.
We observed in our group of patients that an
understanding of their illness and their cognitive change
was far more important than masking. However, we do not
dispute the fact that this and other techniques (acupunc-
ture, yoga, hypnosis, meditation, etc.) can help with
relaxation and thus mitigate tinnitus.
We must distinguish treatments which are specically
for tinnitus from treatments for its comorbidities (anxiety,
depression, incapacity, hypersensitivity to noise, etc.). It
will be more effective for the patient and they will be able
191
to accept the guidelines set by their therapist if their mood
is more optimistic.
There are several treatments which might be useful for
mood, such as antidepressants, but there is not sufcient
evidence as yet to conrm whether treatment with antide-
pressants improves tinnitus.18
Randomised controlled trials have demonstrated that
acupuncture is not effective as treatment for tinnitus.19,20
There are no available data to verify the long term safety
of transcranial magnetic stimulation, but it is a safe treat-
ment short term for patients with tinnitus.21
Findings from direct electrical stimulation of Heschls
gyrus for treating tinnitus indicate that the perception and
distress caused can be modulated or reduced, although the
reason for this has not yet been determined.22
There appears to be agreement that cochlear implanta-
tion can suppress the volume and duration of tinnitus.23,24
Conclusions
Our study reafrms that which was already evident: the
collaboration of psychology experts is necessary in the treat-
ment of subjective tinnitus.
It is also obvious that treatment with cognitive psychol-
ogy methods is essential in mitigating tinnitus.
We are aware that some from the long list of treatments
might be useful, such as masking when the patients visits
start, but we should not forget that it is the patients neg-
ative thinking about the importance of their tinnitus that
needs to be eradicated.
Conict of Interests
The authors have no conicts of interests to declare.
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