VOLUME 10, NUMBER 3, SEPTEMBER 1985

THE AMERICAN TINNITUS ASSOCIATION

TINNITUS - A BIO-PSYCHO-SOCIAL CONDITION?

by Soly Erlandsson and Sven G. Carlsson, Department of Psychology, University of Goteborg, Sweden.

Tinnitus suffering, like many other conditions, can be looked upon in different ways. Western medicine has favoured
a biological approach in explaining etiologies and developing treatments. However, psychological etiologies have been
proposed for a number of somatic illnesses; tinnitus has sometimes been explained as a case of conversion hysteria. Such
tendencies in the past to conceive of somatic complaints as basically biological or psychological phenomena are being
replaced by bio-psycho-social models. Movements like holistic or behavioral medicine stress the importance of exploring
both medical, psychological and social aspects. In our opinion, tinnitus should be understood as a bio-psycho-social
condition.
According to a bio-psycho-social concept, a disturbing tinnitus condition may be the result of a complex and long-standing
interaction, where psychological and social factors contribute . In such cases, one should not expect immediate effects of
any treatment. We have observed, like others, that treatment effects from behaviorally oriented treatment modalities
typically develop over time; the treatment initiates a "virtuous circle" which with time reverses the unfortunate develop-
ment which led to the tinnitus suffering. Developing strategies to attack stress factors or to cope with symptoms can
involve a rather complicated process over a long time, as tonga time, perhaps, as it takes to develop disease symptoms and
distress. For both the patient and his relatives this can be difficult to accept. We are educated to believe in the
miracles of medical treatment and technical rehabilitation. In reality, recovery or improvement due to therapy often
requests active participation by the patient and his family or significant others.
A diagnosis based upon a strictly physiological or a strictly psychological hypothesis about the condition will scarcely
advance our understanding of the suffering by an individual tinnitus patient. We need to make our observations of the
condition within a total perspective and to draw attention simultaneously to the biological, psychological and social
phenomena which seem to be related to the current state as well as to preceding phases. One ad vantage with such a
multi-factorial model has to do with the way we look at "placebo" effects. According to our experience such effects are
frequent in any type of tinnitus treatment. In a study where the main purpose was to iiwestigate placebo-effects in
masker- therapy, we compared a programmable masker with a placebo-device. Seventeen patients received treatment with
masker for six weeks and with placebo for an equally long period. Treatment effects during the placebo period turned out
to be significant; six of the patients reported pronounced treatment effects during the placebo period, to compare with
eight during masker period.
The most common way to define "placebo" seems to be related to the model one has of the condition and the treatment.
With a medical model any effect that cannot be understood in terms of an intended change in the presumed pathophysiology
will be labeled "placebo", and it will not be quite acceptable to use it intentionally. When we accept the psychological
facets of a condition, "placebo" effects become more easily understood, and during the course of therapy such effects can
be used and rendered legitimate, because they reflect the disease concept underlying the therapy. The treatment we have
taken interest in aims at reducing psycho-physiological reactivity in patients with disabling tinnitus.
A psychophysiological treatment
Treatment programs are worked out individually for each patient in accordance with a multi-factorial model of tinnitus
suffering. However, the history-taking, tinnitus measurements (loudness-matching and subjective ratings of tinnitus
loudness) and psychometric tests are general. We have learned that the treatment has to be modified according to informa-
tion provided by the patient during initial phases of treatment. The psychophysiological treatment involves biofeedback
training, progressive relaxation, and counseling. During the biofeedback training the patient has to concentrate on the
masseter and/or frontalis muscle tension, while the home-practice of progressive relaxation training refers to the whole
body and its muscles. The patients are seen once a week, for eight to twelve weeks.
A case study will be outlined for a more detailed description of the training program. The patient, a thirty-seven year
old man with a cochlear hearing impairment in his left ear was referred to the department of Audiology at Sahlgrenska
Hospital. His hearing loss, vertigo and tinnitus were diagnosed as due to Meniere's disease (onset three years ago). The
vertigo had gradually and spontaneously disappeared and was not the cause of the patient's complaint. Tinnitus, in the
left ear only, was estimated with a loudness-matchingprocedure to 25 dB A at 750Hz. The patient complained about tinnitus
interfering with his work and he expressed problems with concentration. He felt an urge to "give back" and irritation was
commonly present both at work and at home. The patient's environmental conditions were somewhat problematic. He
cons is ten rly did overtime-work and felt that his family was set aside by that reason. His working-environment was not very
rewarding, and hostile feelings were sometimes expressed by the people he worked with . The patient interpreted his
responsibility at work, since the tinnitus began, as beingtoofar- reaching, and he was not always confident enough to make
decisions by himself. His wife is a teacher and they have two daughters. The two year old daughter was regularly in the
hospital for observations due to an unusual blood disease. During and after pregnancy his wife was depressed for about two
years, which happened the year before the patient contracted Meniere's disease.

A bio-psycho-social condition?, continued
The patient had unsuccessfully been treated with masking
before the biofeedback treatment began, first with a
conventional masker and then with the programmable masker
used in the study of placebo effects in masker therapy,
described above. The subjective ratings on a zero to nine
degree scale had shown an increase in tinnitus loudness
after masker treatment. The patient's tinnitus was tempor-
arily improved by treatment with placebo. Six months
thereafter, when tinnitus ratings were back at initial
baseline levels. we started a biofeedback training program.
The patient's motivation to try another treatment was rather
high. On a zero to five point scale he answered five to the
following question; "To what extent do you believe that your
tinnitus will decrease due to the biofeedback training you
will get?" During nine biofeedback training sessions the
patient received EMG biofeedback. The electrodes were
placed over frontalis or masseter muscles. Six months after
the last biofeedback session he came for a follow-up
treatment. Before the EMG electrodes were applied to the
patient's forehead or cheek, he was always interviewed about
the progressive relaxation training that he was doing at
home. During the EMG training the patient was asked to
verbally express his thoughts and interpretations of
tinnitus, tension and his daily life situation. He was then
able to express his emotional feelings towards his work and
family situation and to draw his own conclusions about what
was most disturbing to him, and possible causes of his
irritation and difficulties coping with the tinnitus.
After the third biofeedback session the patient starts to
notice that he relaxes more easily. Still he cannot find
any alteration in tinnitus loudness, and tinnitus is still
the cause of some irritation. However, his work situation
has improved somewhat. He also starts to feel that his
private life, e . g. the relations between himself and his
children, is improving.
During the seventh session of biofeedback training the
patient explains that the intensity of his tinnitus sound
has decreased. He isnowusing the progressive relaxation
technique when needed, and without the taped instructions .
He finds it difficult to judge whether his improvement is
due to the relaxation, biofeedback, or to the discussions
during the treatment sessions. He is not aware of the
tinnitus while training with the biofeedback device.
Personally. he has become more self-confident and has
started to feel more secure and "in control" . In his work
as a supervisor he feels more confident and makes his own
decisions more easily.
After a week of disturbing tinnitus following a bad cold,
the patient found it difficult to relax during the EMG
training in the clinic. When he takes the opportunity to
express his worries about his increased tinnitus sound,
however, it helps him to feel more relaxed. Next training
session, the patient has recovered from his old, and his EMG
muscle tension of the frontalis muscles is back to his
normal level (about 2. 5 1J. V). He believes that his ability
to cope with tinnitus has increased. Therefore he is rather
optimistic about his future. He interprets his earlier bad
status partly due to a depressed state of mind. "Others
used to set the rules for me, and I was gradually losing my
strength, but now I am beginning to gain control of my
existence."
At a follow-up session after six months there are several
signs of progressive improvement. Relaxation training has
been generalized so that everyday tension is more reliably
mastered than before. During biofeedback training tension
is !' educed to as low as 1. 9 IJ. V. The patient reports that
tinnitus is totally absent for periods, and otherwise quite
possible handle .

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THE MEASUREMENT OF TINNITUS FOR THE EVALUATION
OF TREATMENT
By Richard S . Tyler-Department of Otolaryngology-Head &
Neck Surgery and Department of Speech Pathology and Audio-
logy, University of Iowa, Iowa City, IA (USA).
The effectiveness of treatments for tinnitus are
difficult to evaluate because tinnitus is subjective in
nature . People report that their tinnitus sounds like a
hissing, it's on the right side, and it is very annoying.
This information is not specific, nor is it quantitative .
Even well-designed double- blind studies which rely on the
patient's impression of whether their tinnitus has changed
are severely limited. Precise measurements are needed
which allow repeatable quantifiable measures of the dif-
ferent characteristics of tinnitus. lt is essential to
quantify tinnitus in a rigorous fashion if we are to be
able to learn its causes, and to objectively evaluate
different treatment schemes.
Tinnitus can be evaluated in a number of ways, and I shall
review some of the more common procedures here. rt must be
emphasized that it is always important to have a coopera-
tive,_ interested patient. Adeg_l!_ate instructions. of. ___ __
practice, and several trials are essential for reliable
results.
Even when the tinnitus is described as being comprised
of several sounds, the patient can be directed to select a
most-prominent pitch. The patient is then asked to manipu-
late the frequency of a pure tone until its pitch is equal
to the most prominent pitch of the tinnitus. (Tyler RS
(1982) In: Raviv J (ed) Uses of computers in aiding the
disabled North-Holland, Amsterdam)
Loudness
The loudness of tinnitus can be evaluated by adjusting the
level of a pure tone until it has the same loudness as the
tinnitus. In regions of profound hearing loss the measure-
ment may be only a few dB (a physical measurement of
intensity) above threshold, whereas in regions of normal
hearing the measurement may be as much as 40 dB above
threshold. (Goodwin PE, Johnson RM ( 1980) Acta Otolaryngol
90:353) However, dB is not a perceptual measurement of
loudness. ln the hearing impaired, a sound only a few dB
above threshold can be very loud; this is called loudness
recruitment. We (Tyler RS, Conrad-Armes D (1983al J Speech
Hear Res 26: 59) have proposed a formula to change these dB
measurements into loudness values considering the effects
of loudness recruitment (see also Penner MJ ( 1984) J Speech
Hear Res 27:274).
Pure-Tone Masking
A tinnitus masking pattern can be measured by measur-
ing the minimum level of a pure tone required to mask the
tinnitus as a function of the masker frequency (Bailey Q
(1979) Australian J Audio!! : 19 )(Feldmann H (1971) Audio-
logy 10:138)(Formby C, Djerdingen DB (1980) Audiology
19:519)(Mitchell C (1983) Audiology 22:73). In some
patients high masker levels must be used to mask the
tinnitus at all masker frequencies. In others, very low
level maskers can mask the tinnitus. In still others, high
3
levels are required away from the tinnitus pitch-match
frequency, but low levels are required close t o this
frequency. (Tyler RS, Conrad-Armes D (1984) J Speech Hear
Res 27:106)
Ipsalteral and contralateral masking
It is interesting to note that oft en tinnitus can be
masked by a noise presented at similar levels in either
ear, even when a person reports hearing tinnitus only in
one ear. (See Footnote 3) . For example, a person with
tinnitus localized to the right ear could mask their
tinnitus with 40 dB of overall noise level in either the
left or the right ear. This effect suggests s ome centr al
component of tinnitus, even in cases where the patient
reports hearing the tinnitus in one ear.
Postmasking effects
One intriguing characteristic of tinnit us occurs when a
masking noise is t urned off. At that time the tinnitus can
remain inaudible for some t ime ( See Foot note 6) (Tyler RS,
Conrad-
Armes D, Smith PA (1984) J Speech Hear Res 27 :466)(Terry
AMP, Jones DM, Dvis BR, SlaterR (1983) BritishJ Audio!
17:245) for some patients, but could get louder in ot hers.
Figure 1 shows a schematic representation of some of the
postmasking patterns that can be observed. First the
patient hears the tinni tus.
The noise then covers up the tinnitus, and the person hears
the noise, but not the tinnitus . After t he termination of
the masker the tinnitus either a) r eturns to normal immedi-
ately, b) r eturns i mmediately but at a softe.r loudness, c)
was absent for a time before gradually returning to normal ,
d ) was absent for a time before abruptly r eturning to
normal, or e) was louder than normal before gradually
ret urning t o normal.
CONCLUSIONS
Several procedures are now available to quantify
tinnitus. These procedures depend upon the cooperation of
the patient, adequate training periods, and several replica-
t ions. One value for such quantification is that tinnitus
patients can be subcategorized. Tinni t us has
c
c
t=
Time
A
,. ___ _
,/' c
E
Figure 1. Schematic tinnit us postmasking effects (see
text ) .
many etiologies and it is very important t o delineate
d iffer ent types of t innitus because one t reatment is
un likely to help all tinnitus patients. Ther efor e , the
determination of tinnitus subcategorization s hou ld direct
t r eatments to s pecific subpopulations of tinnitus patients
and t herefore have better c hance of success.

SELF-HELP GROUP COORDINATORS: PLEASE NOTE
ATA cont inues to receive many requests from people who want
to join a self- help group. Will you please provide us with
your current status. Is your group meeting regularly? If
so, what is your next meeting date and place? If you are
functioning as a telephone network for people in your
locality we would like to know that. Please let us know
what your group has been doing this past year . Did you
have guest speakers , who? Did your group participate in
any resear ch projects, describe? Has your group engaged in
community service such as providing information about
tin n itus to senior ci t i zens groups or to military
establishments? Have you called your local TV station to
ask them to play the ATA public service announcements?
Ha ve you participated in local health-fairs to help spread
the word about tinnitus to those who need information? We
will try to publish an issue of "Tinnitus Tidings", our
gang-letter for self- help groups just as soon as we receive
this information from you.

LETTER FROM A NEW MEMBER
(Ed. note : The following letter raises interesting
questions. This gentleman's experiences have been echoed
by many tinnitus sufferers. Tinnitus can arise following
some specific incident, as this man's did, but sometimes it
can s neak up on a person with a very gradual onset over
many years. The point of printing this letter is to show
t hat the patient may be frustrated time and time again in
the search for help . Health professionals are frustrated
too by t he problem of tinnitus. Some will make an effort
to help the patient cope but some neglect their responsi-
bility and simply tell the patient to "learn to live with
it" offering little if any help . ATA exists to promote the
research that can provide answers to the problem of
tinnitus , it also exists to help educate people, both
p rofessionals and laymen, about the problems of tinni tus
and how best to manage them. )
"My tinni tus began i nJ"la.l?ch, l946inLetterman Army General
Hospital in San Francisco the day following a caloric test
given in the diagnosis of migraine headaches. This test
involves the injection of hot and cold water in the ears to
pr oduce vertigo. After disharge from the Army, I found it
quite difficult to "get used to it" but, after several
years, was able to cope with the problem and lead a
somewhat normal life. During this time [ tried many
different suggestions by both otologists and general
pract itioners who prescribed mild medications such as
phenergan and small doses of valium, dental plates to
correct a mal-occlusion, deviated septum correction,
physical therapy, and probably others ! can't recall . "
"I filed claims with the VA and subsequent appeals but was
not successful in obtaining any relief ... " "After handling
my problem for some thirty-five years, I decided to have
some wax removed by my otologist who had been seeing me
every two or three years to see if anything new had been
developed in the treatment of tinnitus. Unfortunately,
where he had been using an instrument to remove wax, he
used a new method of taking it our by vacuum. The immed-
iate response to that technique was a violent return of the
ringing that has continued since with some days of minor
relief. It has been very difficult since that time to deal
with it, and most depressing, adversely affecting the
quality of my life . . . " ''I am currently off alcohol ,
caffeine, nicotine, aspirin , and anything else that has
been suggested that could possibly aggravate the ringing.
I am also into my twelfth session of accupuncture, being
advised that it might take twenty to thirty sessions to
show relief." "It might be interesting to note that there
are days , on awakening, the ringing is very mild and stays
t ha t way during the day. After falling asleep quite
easily, I can wake up in an hour or two with the ringing
q uite sever e, and although I can get back to sleep,
I might wake up a time or two with the ringing and it 1'1.ill
s tay that way the balance of the day. If any change takes
place, it will be during sleep . It has also occurred to me
that there might be some effect as the result of atmos-
p heric pressure. Has this thought been explored? . ..
(Thank you, Mr. RCT, for allowing us to print excerpts from
your letter. )
4
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Published by the
AMERICAN TINNITUS ASSOCI ATION
A
under the l.aws of Ol'egon
SCIENTI FIC
ADVISORY BOARD
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Chicago, Illinois
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Portland, Oregon
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Memphis, Tennessee
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United States Senate
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