Living With a Sound You Can’t Turn Off

Shortly after my 70th birthday, a high-pitched hum began in my left ear. I noticed it only during quiet times but soon realized that it never went away.
An ear, nose and throat specialist (otolaryngologist) examined my ears and took a thorough medical history that included questions about noise exposure and drugs I take. An audiologist checked my hearing.
Diagnosis: tinnitus, with a mild hearing loss in the upper range that closely matched the pitch of the hum.
Although the hum was not particularly disturbing, I asked what might be done if it should get loud enough to interfere with my life and ability to hear speech clearly (about 85 percent of tinnitus cases are accompanied by hearing loss). The answer was that I could be fitted with a hearing aid.
But since my tinnitus is still mild, no mention was made of anything that might relieve the constant noise in my head.
Tinnitus is a chronic noise of varying intensity, loudness and pitch that has no external source. Rather, it seems to come from within a person’s head. It is most apparent to the sufferer when all is quiet and may not be noticed when the person is otherwise distracted — while participating in physical activity, for example, or listening to music.
There is currently no cure for tinnitus, a potentially life-disrupting condition that affects about 10 to 20 percent of people, mostly those over age 65, but also many veterans of the wars in Iraq and Afghanistan. Among possible causes are head and neck injuries, drugs that damage the ear, blood vessel disease, autoimmune disorders, ear conditions and disorders of the temporomandibular joint.
Until recently, no treatment had been shown to have lasting effectiveness in controlled clinical trials, despite a host of remedies variously endorsed by hearing specialists and commercial interests.
In addition to a hearing aid, the most commonly prescribed remedy is a so-called masking device, a white-noise machine that introduces natural or artificial sound into the sufferer’s ears in an attempt to suppress the perceived ringing. But eventually the noise of the masker can become as disruptive as the tinnitus.
“When patients respond poorly to the masking device, they are often told they haven’t used it long or consistently enough,” said Rilana F. F. Cima, a psychologist and researcher in the Netherlands.
Fear and Anxiety
Dr. Cima said in an interview that, like me, most people with tinnitus function fairly well. But for about 3 percent of people with the condition, it is extremely disabling, causing intense distress, fear and anxiety, and leaving them unable to function.
“Patients say the sound is driving them crazy,” Dr. Cima said. “Their negative reaction to not wanting to hear it creates daily life impairment.” She said patients would do almost anything to avoid hearing the sound in their heads and the feelings of fear and anxiety that result.
Recently Dr. Cima’s team demonstrated the effectiveness of a multidisciplinary, psychology-based approach to this problem. The technique, published last spring in The Lancet, does not make the ringing go away, but it does show that now there is real hope for relief for people whose tinnitus impairs their ability to work, sleep and enjoy life.
In an accompanying editorial, Dr. Berthold Langguth of the University of Regensburg in Germany, an international authority on tinnitus, said the team’s findings “overcome the idea that nothing can be done to treat tinnitus” and provide “a clear statement against therapeutic nihilism.”
James Henry, a specialist in auditory rehabilitation at the Veterans Administration Medical Center in Portland, Ore., where many veterans with traumatic brain injuries are treated for tinnitus, said that Dr. Cima had done “probably the best study to date, a good job that is advancing the field.”
An Improved Approach
The three-month treatment developed and carefully tested by the Dutch team is based on cognitive behavioral therapy and relies on principles of exposure therapy long proven effective to treat phobias. While the use of cognitive behavioral therapy for tinnitus is not new, the team’s demonstration of a scientifically validated, comprehensive approach to the problem offers a therapeutic blueprint that others can use.
Unlike the use of a tinnitus masker, the treatment is simple, relatively brief and does not require patients to purchase or use devices to gain relief. If necessary, patients who “relapse” can return for a brief therapeutic brush-up.
Dr. Cima’s team enrolled 492 patients with varying degrees of tinnitus and randomly assigned them to receive either usual care or “specialized” care. Usual care, in the Netherlands as well as in the United States, involves a medical exam and hearing test, typically followed by a prescription for a hearing aid and/or masking device.
Patients may also be given antidepressants, anti-anxiety drugs, sleep aids or other medication to relieve emotional distress and other disabling symptoms.
The Dutch treatment relies solely on psychological techniques. Following an education session about tinnitus and lessons in deep relaxation, patients are gradually exposed to an external source of the very ringing they hear in their heads. After 10 or 12 sessions, they become habituated to it and no longer find it threatening.
It is not the noise itself but “patients’ extremely negative reaction to it that creates daily life impairment,” Dr. Cima explained. “Patients are continuously stressed and fearful of it. It becomes a sign of a danger from which they must escape.”
She likened the approach to helping people overcome their fear of spiders by inducing deep relaxation and gradually introducing them to increasingly realistic objects of their fear.
“They may never learn to love spiders, but they can live with them more comfortably,” Dr. Cima said.
Dr. Henry of the veterans medical center, who has been involved in tinnitus research for a quarter century, said his team uses a similar approach with five treatment sessions, which “takes care of about 95 percent of cases,” he said.
“Lots of veterans get tinnitus in association with traumatic brain injuries, but the tinnitus is often permanent even after these other injuries are resolved,” Dr. Henry said. “We teach them skills that enable them to manage their tinnitus. They learn to reframe the problem in a more positive way. It’s not a cure — nobody has a cure — but we’re able to help most veterans and enable them to live a normal life.”
A cure may emerge from findings of changes in the brains of tinnitus patients that are being revealed through sophisticated imaging techniques.

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