A proof-of-concept study of the benefits of a single-session of tinnitus instruction and counselling with homework on tinnitus.

Objective: The objective of this study was to provide proof-of-concept of a single session of tinnitus instruction and counselling with and without homework.Design: A mixed-method design using questionnaires and thematic evaluation of qualitative data was implemented.Study sample: Sixteen participants received instruction in a single, one-to-one counselling session; eight participants additionally undertook homework consisting of either positive visualisation augmented by sound or a workbook of written and drawing activities supporting the instruction provided in the counselling session. All participants completed questionnaires just before and 3 weeks after the intervention, half were interviewed 3 weeks following the intervention.Results: Average tinnitus functional index (TFI) scores were 45 (SD 25) before and 29 (SD 23) following counselling, with a change of 4.8 or greater recorded in 75% and change of 13 points or greater in 50% of participants. Both counselling and counselling with homework showed similar changes in the TFI. This finding was supported by the qualitative analysis from which a model consisting of the themes of counselling benefit, content, application and homework benefit was derived.Conclusions: This study provides proof-of-concept of a single tinnitus instruction and counselling session, based on an ecological model of tinnitus.

Auditory Streaming and Prediction in Tinnitus Sufferers.

OBJECTIVES: The aim of this study was to determine whether auditory streaming (segregation of incoming sounds into separate sound sources) and the ability to anticipate future auditory events are affected in tinnitus sufferers compared with nontinnitus controls with matched levels of hearing. It was hypothesized that tinnitus would result in abnormal electroencephalography responses to tone deviants and tone omissions compared to controls for frequencies near the pitch of tinnitus, and this should correspond with increased levels of cortical γ and θ oscillatory rhythms. DESIGN: Sixteen individuals with tinnitus (10 men and 6 women; age, 53.44; SD, 12.92 years) and 14 control participants (8 men and 6 women; age, 50.25; SD, 18.54 years) took part in the study. A modified version of the ABA streaming paradigm, with repeating triplet pattern of two frequencies (A and B) presented as A-B-A, was used to examine deviant-related prediction error. Omission-related prediction errors were examined using a modified version of a tone-omission paradigm. Regions of interest were frontocentral, left frontal, right frontal, and temporal lobes. RESULTS: A larger N1c waveform was elicited in the absence of any tone deviation within the left primary auditory cortex of tinnitus participants. No differences were present between groups for omissions. The only difference in oscillatory band activity between the two groups in this study was in response to tones 7 semitones different from tinnitus pitch, with significantly lower ß-2 band activity present for the tinnitus group, correlating most with activity within the right inferior occipital gyrus. CONCLUSIONS: The findings from this study imply that cortical-level auditory stream segregation is altered among individuals with tinnitus.

A feasibility study of predictable and unpredictable surf-like sounds for tinnitus therapy using personal music players.

OBJECTIVE: To evaluate the feasibility of predictable or unpredictable amplitude-modulated sounds for tinnitus therapy. DESIGN: The study consisted of two parts. (1) An adaptation experiment. Loudness level matches and rating scales (10-point) for loudness and distress were obtained at a silent baseline and at the end of three counterbalanced 30-min exposures (silence, predictable and unpredictable). (2) A qualitative 2-week sound therapy feasibility trial. Participants took home a personal music player (PMP). STUDY SAMPLE: Part 1: 23 individuals with chronic tinnitus and part 2: seven individuals randomly selected from Part 1. RESULTS: Self-reported tinnitus loudness and annoyance were significantly lower than baseline ratings after acute unpredictable sound exposure. Tinnitus annoyance ratings were also significantly lower than the baseline but the effect was small. The feasibility trial identified that participant preferences for sounds varied. Three participants did not obtain any benefit from either sound. Three participants preferred unpredictable compared to predictable sounds. Some participants had difficulty using the PMP, the average self-report hours of use were low (less <1 h/day). CONCLUSIONS: Unpredictable surf-like sounds played using a PMP is a feasible tinnitus treatment. Further work is required to improve the acceptance of the sound and ease of PMP use.

Anxiety and depression, personality traits relevant to tinnitus: A scoping review.

OBJECTIVE: Scoping reviews of existing literature were conducted to identify key personality traits relevant to tinnitus, and examine the relationship between affective disorders and tinnitus. DESIGN: The methodological framework of Arksey and O'Malley was followed. STUDY SAMPLE: Sixty studies were chosen for charting the data, 14 studies examined personality traits exclusively, 31 studies examined affective disorders exclusively, and 15 studies investigated both. RESULTS: The presence of one or more specific personality traits of high neuroticism, low extraversion, high stress reaction, higher alienation, lower social closeness, lower well-being, lower self control, lower psychological acceptance, presence of a type D personality, and externalized locus of control were associated with tinnitus distress. Anxiety and depression were more prevalent among the tinnitus clinical population and at elevated levels. CONCLUSIONS: Personality traits have a consistent association with the distress experienced by adult tinnitus help-seekers, and help-seekers are also more likely to experience affective symptoms and/or disorders.

Prediction of tinnitus masking benefit within a case series using a spiking neural network model.

Masking has been widely used as a tinnitus therapy, with large individual differences in its effectiveness. The basis of this variation is unknown. We examined individual tinnitus and psychological responses to three masking types, energetic masking (bilateral broadband static or rain noise [BBN]), informational masking (BBN with a notch at tinnitus pitch and 3-dimensional cues) and a masker combining both effects (BBN with spatial cues). Eleven participants with chronic tinnitus were followed for 12 months, each person used each masking approach for 3 months with a 1 month washout-baseline. The Tinnitus Functional Index (TFI), Tinnitus Rating Scales, Positive and Negative Affect Scale and Depression Anxiety Stress Scales, were measured every month of treatment. Electroencephalography (EEG) and psychoacoustic assessment was undertaken at baseline and following 3 months of each masking sound. The computational modeling of EEG data was based on the framework of brain-inspired Spiking Neural Network (SNN) architecture called NeuCube, designed for this study for mapping, learning, visualizing and classifying of brain activity patterns. EEG was related to clinically significant change in the TFI using the SNN model. The SNN framework was able to predict sound therapy responders (93% accuracy) from non-responders (100% accuracy) using baseline EEG recordings. The combination of energetic and informational masking was an effective treatment sound in more individuals than the other sounds used. Although the findings are promising, they are preliminary and require confirmation in independent and larger samples.

Behavioral Outcomes and Neural Network Modeling of a Novel, Putative, Recategorization Sound Therapy.

The mechanisms underlying sound's effect on tinnitus perception are unclear. Tinnitus activity appears to conflict with perceptual expectations of "real" sound, resulting in it being a salient signal. Attention diverted towards tinnitus during the later stages of object processing potentially disrupts high-order auditory streaming, and its uncertain nature results in negative psychological responses. This study investigated the benefits and neurophysiological basis of passive perceptual training and informational counseling to recategorize phantom perception as a more real auditory object. Specifically, it examined underlying psychoacoustic correlates of tinnitus and the neural activities associated with tinnitus auditory streaming and how malleable these are to change with targeted intervention. Eighteen participants (8 females, 10 males, mean age = 61.6 years) completed the study. The study consisted of 2 parts: (1) An acute exposure over 30 min to a sound that matched the person's tinnitus (Tinnitus Avatar) that was cross-faded to a selected nature sound (Cicadas, Fan, Water Sound/Rain, Birds, Water and Bird). (2) A chronic exposure for 3 months to the same "morphed" sound. A brain-inspired spiking neural network (SNN) architecture was used to model and compare differences between electroencephalography (EEG) patterns recorded prior to morphing sound presentation, during, after (3-month), and post-follow-up. Results showed that the tinnitus avatar generated was a good match to an individual's tinnitus as rated on likeness scales and was not rated as unpleasant. The five environmental sounds selected for this study were also rated as being appropriate matches to individuals' tinnitus and largely pleasant to listen to. There was a significant reduction in the Tinnitus Functional Index score and subscales of intrusiveness of the tinnitus signal and ability to concentrate with the tinnitus trial end compared to baseline. There was a significant decrease in how strong the tinnitus signal was rated as well as ratings of how easy it was to ignore the tinnitus signal on severity rating scales. Qualitative analysis found that the environmental sound interacted with the tinnitus in a positive way, but participants did not experience change in severity, however, characteristics of tinnitus, including pitch and uniformity of sound, were reported to change. The results indicate the feasibility of the computational SNN method and preliminary evidence that the sound exposure may change activation of neural tinnitus networks and greater bilateral hemispheric involvement as the sound morphs over time into natural environmental sound; particularly relating to attention and discriminatory judgments (dorsal attention network, precentral gyrus, ventral anterior network). This is the first study that attempts to recategorize tinnitus using passive auditory training to a sound that morphs from resembling the person's tinnitus to a natural sound. These findings will be used to design future-controlled trials to elucidate whether the approach used differs in effect and mechanism from conventional Broadband Noise (BBN) sound therapy.

An Evaluation of a Continuing Education Workshop for Audiologists on the Assessment and Management of Tinnitus.

INTRODUCTION: Tinnitus assessment and management is an important component of audiology. The benefits of continuing education (CE) workshops in the field of tinnitus have not been published. This study evaluated the outcomes of a workshop centered around a Sound Therapy and Aural Rehabilitation for Tinnitus (START) framework. Our hypotheses were that a CE workshop would (1) be useful, (2) improve clinician's knowledge and willingness to undertake tinnitus practice, and (3) result in learners using knowledge gained in their practice. METHODS: Twenty-five participants attending a 3-day tinnitus workshop were invited to complete an evaluation immediately and 3 months after the workshop's completion. The workshop consisted of seminars and practical sessions. The pedagogical approaches employed were experiential (theory building, reflection, and testing) and community of practice (shared experiences). RESULTS: Participants reported on a 5-point Likert scale (1 = not useful-5 = excellent) a high level of satisfaction both immediately after the workshop (ratings of usefulness: mean, 4.8; SD, 0.4; willingness to practice: 4.6; SD. 0.6; ability to manage: 4.6; SD, 0.5; all "excellent" ratings) and 3 months later (ratings of usefulness: mean, 4.2; SD, 0.9, "very useful;" willingness to practice: 4.6; SD, 0.6, "excellent;" ability to manage: 4.1; SD. 0.5, "very useful"). Open-ended questions indicated participants made changes in their practice that reflected material provided in the CE. CONCLUSION: The workshop was successful in improving knowledge and confidence of audiologists in undertaking tinnitus assessment and management, but the need for ongoing support and supervision was a common theme.

Sound therapy and aural rehabilitation for tinnitus: a person centred therapy framework based on an ecological model of tinnitus.

Purpose: Tinnitus is a common oto-neurological complaint often accompanying hearing loss. In this perspective on rehabilitation we describe a framework for sound therapy and aural rehabilitation of tinnitus based on the ecological model of tinnitus. Method: A thematic network analysis-based approach was used to relate aural rehabilitation methods to the ecological model of tinnitus and the client-oriented scale of improvement in tinnitus. Results: Aural rehabilitation methods were mapped to concepts of: (1) Context, (2) presence of sound and (3) reaction to sound. A global theme was: adaptation to sound. The framework is the result of an iterative and cumulative research program exploring tinnitus as the outcome of the relationship between individual psychoacoustics and psychosocial factors including context of perception. Conclusions: The intent of this framework is to help guide audiologists managing tinnitus. The framework has been useful in our clinic as illustrated by a case study. The benefits of this approach relative to standard care needs to be independently ascertained. Implications for Rehabilitation Tinnitus is a common oto-neurological complaint that when severe can be very disabling. Tinnitus is very heterogeneous as a consequence of this no one treatment is suitable for everyone. The sound therapy and aural rehabilitation for tinnitus framework is designed to assist audiologists in clinical planning that addresses individual needs. The framework is the result of an iterative and cumulative research program exploring tinnitus as the outcome of the relationship between individual psychoacoustics and psychosocial factors including context of perception.

A Review of Auditory Prediction and Its Potential Role in Tinnitus Perception.

BACKGROUND: The precise mechanisms underlying tinnitus perception and distress are still not fully understood. A recent proposition is that auditory prediction errors and related memory representations may play a role in driving tinnitus perception. It is of interest to further explore this. PURPOSE: To obtain a comprehensive narrative synthesis of current research in relation to auditory prediction and its potential role in tinnitus perception and severity. RESEARCH DESIGN: A narrative review methodological framework was followed. DATA COLLECTION AND ANALYSIS: The key words Prediction Auditory, Memory Prediction Auditory, Tinnitus AND Memory, Tinnitus AND Prediction in Article Title, Abstract, and Keywords were extensively searched on four databases: PubMed, Scopus, SpringerLink, and PsychINFO. All study types were selected from 2000-2016 (end of 2016) and had the following exclusion criteria applied: minimum age of participants <18, nonhuman participants, and article not available in English. Reference lists of articles were reviewed to identify any further relevant studies. Articles were short listed based on title relevance. STUDY SAMPLE: After reading the abstracts and with consensus made between coauthors, a total of 114 studies were selected for charting data. RESULTS: The hierarchical predictive coding model based on the Bayesian brain hypothesis, attentional modulation and top-down feedback serves as the fundamental framework in current literature for how auditory prediction may occur. Predictions are integral to speech and music processing, as well as in sequential processing and identification of auditory objects during auditory streaming. Although deviant responses are observable from middle latency time ranges, the mismatch negativity (MMN) waveform is the most commonly studied electrophysiological index of auditory irregularity detection. However, limitations may apply when interpreting findings because of the debatable origin of the MMN and its restricted ability to model real-life, more complex auditory phenomenon. Cortical oscillatory band activity may act as neurophysiological substrates for auditory prediction. Tinnitus has been modeled as an auditory object which may demonstrate incomplete processing during auditory scene analysis resulting in tinnitus salience and therefore difficulty in habituation. Within the electrophysiological domain, there is currently mixed evidence regarding oscillatory band changes in tinnitus. CONCLUSIONS: There are theoretical proposals for a relationship between prediction error and tinnitus but few published empirical studies.

Corrigendum: A Mixed-Methods Trial of Broad Band Noise and Nature Sounds for Tinnitus Therapy: Group and Individual Responses Modeled under the Adaptation Level Theory of Tinnitus.

[This corrects the article on p. 44 in vol. 9, PMID: 28337139.].

A State-of-the-Art Review: Personalization of Tinnitus Sound Therapy.

Background: There are several established, and an increasing number of putative, therapies using sound to treat tinnitus. There appear to be few guidelines for sound therapy selection and application. Aim: To review current approaches to personalizing sound therapy for tinnitus. Methods: A "state-of-the-art" review (Grant and Booth, 2009) was undertaken to answer the question: how do current sound-based therapies for tinnitus adjust for tinnitus heterogeneity? Scopus, Google Scholar, Embase and PubMed were searched for the 10-year period 2006-2016. The search strategy used the following key words: "tinnitus" AND "sound" AND "therapy" AND "guidelines" OR "personalized" OR "customized" OR "individual" OR "questionnaire" OR "selection." The results of the review were cataloged and organized into themes. Results: In total 165 articles were reviewed in full, 83 contained sufficient details to contribute to answering the study question. The key themes identified were hearing compensation, pitched-match therapy, maskability, reaction to sound and psychosocial factors. Although many therapies mentioned customization, few could be classified as being personalized. Several psychoacoustic and questionnaire-based methods for assisting treatment selection were identified. Conclusions: Assessment methods are available to assist clinicians to personalize sound-therapy and empower patients to be active in therapy decision-making. Most current therapies are modified using only one characteristic of the individual and/or their tinnitus.

A Mixed-Methods Trial of Broad Band Noise and Nature Sounds for Tinnitus Therapy: Group and Individual Responses Modeled under the Adaptation Level Theory of Tinnitus.

Objectives: A randomized cross-over trial in 18 participants tested the hypothesis that nature sounds, with unpredictable temporal characteristics and high valence would yield greater improvement in tinnitus than constant, emotionally neutral broadband noise. Study Design: The primary outcome measure was the Tinnitus Functional Index (TFI). Secondary measures were: loudness and annoyance ratings, loudness level matches, minimum masking levels, positive and negative emotionality, attention reaction and discrimination time, anxiety, depression and stress. Each sound was administered using MP3 players with earbuds for 8 continuous weeks, with a 3 week wash-out period before crossing over to the other treatment sound. Measurements were undertaken for each arm at sound fitting, 4 and 8 weeks after administration. Qualitative interviews were conducted at each of these appointments. Results: From a baseline TFI score of 41.3, sound therapy resulted in TFI scores at 8 weeks of 35.6; broadband noise resulted in significantly greater reduction (8.2 points) after 8 weeks of sound therapy use than nature sounds (3.2 points). The positive effect of sound on tinnitus was supported by secondary outcome measures of tinnitus, emotion, attention, and psychological state, but not interviews. Tinnitus loudness level match was higher for BBN at 8 weeks; while there was little change in loudness level matches for nature sounds. There was no change in minimum masking levels following sound therapy administration. Self-reported preference for one sound over another did not correlate with changes in tinnitus. Conclusions: Modeled under an adaptation level theory framework of tinnitus perception, the results indicate that the introduction of broadband noise shifts internal adaptation level weighting away from the tinnitus signal, reducing tinnitus magnitude. Nature sounds may modify the affective components of tinnitus via a secondary, residual pathway, but this appears to be less important for sound effectiveness. The different rates of adaptation to broadband noise and nature sound by the auditory system may explain the different tinnitus loudness level matches. In addition to group effects there also appears to be a great deal of individual variation. A sound therapy framework based on adaptation level theory is proposed that accounts for individual variation in preference and response to sound. Clinical Trial Registration: www.anzctr.org.au, identifier #12616000742471.

The Personality Profile of Tinnitus Sufferers and a Nontinnitus Control Group.

BACKGROUND: Chronic tinnitus (phantom perception of sound) significantly disrupts quality of life in 15-20% of those who experience it. Understanding how certain personality traits impact tinnitus perception and distress can be beneficial for the development of interventions to improve the lives of tinnitus sufferers. PURPOSE: Four key self-reported personality traits (social closeness, stress reaction, alienation, and self-control) were identified from previous research as being associated with tinnitus. These were compared between tinnitus and age-, gender-, and hearing level-matched nontinnitus controls to see whether underlying profile differences exist, and if personality traits levels correlate with various tinnitus characteristics assessed in typical clinical questionnaires. RESEARCH DESIGN: A Web-based personality survey was administered comprising of self-control, stress reaction, alienation, and social closeness subscale questions of the Multidimensional Personality Questionnaire, the Hearing Handicap Inventory-Screening Version, TFI, and the Tinnitus Case History Questionnaire. STUDY SAMPLE: A total of 154 participants with tinnitus (81 males, 73 females, mean age = 62.6 yr) and 61 control (32 males, 29 females, mean age = 59.62 yr) participants were recruited via e-mail invitations to a tinnitus research clinic database, poster, and social media Web site advertising. DATA COLLECTION AND ANALYSIS: Statistical analysis was conducted using parametric statistics and IBM SPSS® Version 22 software. RESULTS: Tinnitus sufferers displayed higher levels of stress reaction, lower social closeness, lower self-control, and higher alienation than the control group (p < 0.05). Alienation was related to tinnitus pitch and self-reported hyperacusis measured using the Tinnitus Case History Questionnaire (p < 0.05). Stress reaction correlated with self-reported hyperacusis, whether tinnitus sufferers had sought other treatments, and whether loud sounds make the tinnitus worse (p < 0.05). CONCLUSIONS: The four personality traits examined in this study exhibited a consistent association with tinnitus perception and distress, and differentiated tinnitus sufferers from nontinnitus control. Some of the traits also correlated significantly with certain characteristics measured in tinnitus history questionnaires. Personality traits are described in relation to "maladaptive" residuals under the Adaptation Level Theory model of tinnitus. The results of the study suggest that certain personality traits correlate with the clinical presentation of tinnitus.

Examining the short term effects of emotion under an Adaptation Level Theory model of tinnitus perception.

OBJECTIVES: Existing evidence suggests a strong relationship between tinnitus and emotion. The objective of this study was to examine the effects of short-term emotional changes along valence and arousal dimensions on tinnitus outcomes. Emotional stimuli were presented in two different modalities: auditory and visual. The authors hypothesized that (1) negative valence (unpleasant) stimuli and/or high arousal stimuli will lead to greater tinnitus loudness and annoyance than positive valence and/or low arousal stimuli, and (2) auditory emotional stimuli, which are in the same modality as the tinnitus, will exhibit a greater effect on tinnitus outcome measures than visual stimuli. STUDY DESIGN: Auditory and visual emotive stimuli were administered to 22 participants (12 females and 10 males) with chronic tinnitus, recruited via email invitations send out to the University of Auckland Tinnitus Research Volunteer Database. Emotional stimuli used were taken from the International Affective Digital Sounds- Version 2 (IADS-2) and the International Affective Picture System (IAPS) (Bradley and Lang, 2007a, 2007b). The Emotion Regulation Questionnaire (Gross and John, 2003) was administered alongside subjective ratings of tinnitus loudness and annoyance, and psychoacoustic sensation level matches to external sounds. RESULTS: Males had significantly different emotional regulation scores than females. Negative valence emotional auditory stimuli led to higher tinnitus loudness ratings in males and females and higher annoyance ratings in males only; loudness matches of tinnitus remained unchanged. The visual stimuli did not have an effect on tinnitus ratings. The results are discussed relative to the Adaptation Level Theory Model of Tinnitus. CONCLUSIONS: The results indicate that the negative valence dimension of emotion is associated with increased tinnitus magnitude judgements and gender effects may also be present, but only when the emotional stimulus is in the auditory modality. Sounds with emotional associations may be used for sound therapy for tinnitus relief; it is of interest to determine whether the emotional component of sound treatments can play a role in reversing the negative responses discussed in this paper.