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Tinnitus Retraining Therapy: Update 2008—An Interview with Pawel Jastreboff, PhD, ScD 

The Academy’s Web Content Editor, Douglas L. Beck, AuD, sat down with Dr. Jastreboff, to discuss the uses and best scenarios for TRT and more.

Academy: Good Morning, Pawel. Thanks for meeting with me once again.

Jastreboff: Hi, Doug. Thank you for the kind invitation.

Academy: Pawel, if you don’t mind, may I ask where you earned your doctorate?

Jastreboff: I earned my doctorate in neuroscience at the Polish Academy of Sciences. My dissertation was related to the auditory projections to the cerebellum, and my project had to do with neural plasticity.

Academy: Very good. And when did you first start to work with tinnitus patients?

Jastreboff: I opened my first tinnitus clinic at the University of Maryland at Baltimore in 1990. At that time, we used an early version of Tinnitus Retraining Therapy (TRT) based on the principles I had developed in the mid-1980s at Yale. Basically it was clinical implementation of the neurophysiological model of tinnitus. I postulated involvement of the limbic (emotional) and the autonomic nervous systems in tinnitus. Fortunately, this was confirmed 12 years later by Lockwood and Salvi and they published their results in January 1998. One important principle of that model is the realization that the brain is very plastic and we can intervene to change and correct neural pathways and get improved outcomes for tinnitus patients.

Academy: Pawel, what can you tell me about the incidence of tinnitus in the United States?

Jastreboff: Tinnitus is very common. It impacts about 17 percent of the population. So assuming there are some 310 million people in the United States, that means about 53 million have tinnitus. Of course, for the majority, tinnitus is just an annoyance and not something they need or seek help for. However, for some 4 percent of the population (about 12 million people), tinnitus causes significant suffering and discomfort, and those are the people we try to help.

Academy: And when we talk about the population of candidates for TRT, would you say it includes those with subjective or objective tinnitus (somatosounds) or perhaps both?

Jastreboff: TRT is useful for both populations. TRT is aimed at habituating reactions induced by tinnitus and subsequently, the perception of tinnitus as well. It works at the level of connections between the auditory system and other systems in the brain, so whether it is, tinnitus (or somatosound) is secondary. If the patient experiences distress and suffering from their tinnitus, TRT can usually help regardless of tinnitus etiology. One thing to keep in mind is there’s a big difference between the mechanisms of perception of tinnitus and the reaction to tinnitus. The primary goal of TRT is work on the reaction side of the equation.

Academy: Okay. And is it fair to say the goal of TRT is not to actually eliminate the tinnitus, but to better manage it?

Jastreboff: Not really. TRT is not aimed at management of tinnitus, but at removing the source of the problem—inappropriate connections between the auditory and other systems in the brain that are responsible for negative reactions evoked by tinnitus. These connections are governed by principles of conditioned reflexes and consequently the treatment uses methods for retraining conditioned reflexes at conscious and subconscious levels.

The goal is to retrain the patient’s brain so the tinnitus signal is treated similarly to the sound of a refrigerator. In other words, most people are not aware of its presence, but when they do hear it, it is not bothersome.

Academy: How does TRT make this happen?

Jastreboff: TRT uses specific counseling to reclassify tinnitus to a category of neutral stimuli and sound therapy to weaken the signal of tinnitus to achieve habituation to tinnitus. TRT appears to be successful in about 80 percent of the cases and then the patient is only aware of tinnitus a small fraction of the time, for instance, when they focus their attention on it. Notably, even then, their tinnitus is evoking very little annoyance, or is not annoying or bothersome at all.

Academy: So TRT does not advocate masking?

Jastreboff: Correct. TRT retrains reflexes involving the auditory system and the limbic and autonomic nervous systems. TRT retrains the subconscious auditory pathway to block the tinnitus signal. TRT consists of two components: (1) intensive one-on-one directive counseling and (2) sound therapy, frequently utilizing ear-level devices (low level sound generators, hearing aids or combination instruments of hearing aids and sound generators combined in one shell). But specifically to masking, it should be avoided in TRT, because one cannot habituate to a signal one cannot detect.

Academy: Pawel, I think I read tinnitus patients often have hyperacusis—is that right?

Jastreboff: Yes. Hyperacusis is one aspect of decreased tolerance of sound (the other is dislike of sound—misophonia), and it, too, can be a serious problem. Some patients have hyperacusis without tinnitus as their chief complaint, but about 30 percent of the tinnitus patients do report hyperacusis and 60 percent misophonia.

Academy: And I suspect hyperacusis would also be susceptible to TRT therapy?

Jastreboff: Yes, Tinnitus Retraining Therapy can restore normal sensitivity to sound, treating or even removing (providing a cure) for both hyperacusis and misophonia.

Academy: Pawel, I know you offer classes for audiologists and other professionals that work with tinnitus patients. If the readers want to get more information, where do they get that?

Jastreboff: They can visit the Web site, www.tinnitus-pjj.com to get updates and more information.

Academy: And lastly, Pawel, if you don’t mind, can you list some of your most recent books and articles on tinnitus and hyperacusis?

Jastreboff: My pleasure, Doug.

Academy: Thanks Pawel. It’s always a pleasure speaking with you.

Jastreboff: Thanks, Doug. I appreciate your interest in my work.

For More Information, References and Recommendations:
**Jastreboff, M.M. and Jastreboff, P.J. Decreased sound tolerance and Tinnitus Retraining Therapy (TRT). Australian and New Zealand Journal of Audiology. 24(2):74-81, 2002.

**Lux-Wellenhof G, Hellweg FC: Longterm follow-up study of TRT in Frankfurt; R. B. Patuzzi, (ed): Proceedings of the Seventh International Tinnitus Seminar, Perth, Australia: March 5-9, 2002. Perth, Australia, Physiology Dept., University of Western Australia, 2002.

Jastreboff, P.J. and Jastreboff, M.M. Tinnitus and hyperacusis. In: Ballenger’s Otorhinolaryngology Head and Neck Surgery. 16th edition. eds J.J. Ballenger and J.B. Snow Jr. Singular Publishing, San Diego, Ch 22: 456-471, 2003.

Jastreboff, P.J., Jastreboff, M.M. Tinnitus Retraining Therapy for patients with tinnitus and decreased sound tolerance. Otolaryngologic Clinics of North America, 36:321-336, 2003.

***Jastreboff, P.J., Hazell, J.W.P. Tinnitus Retraining Therapy: Implementing the Neurophysiological Model. Cambridge University Press, pp 276, 2004.

**Henry, J.A., Schechter, M.A., Zaugg, T.L., Griest, S.E., Jastreboff, P.J., Vernon, J.A., Kaelin, C., Meikle, M.B., Lyons, K.S., Stewart, B.J. Outcomes of clinical trial: Tinnitus Masking vs. Tinnitus Retraining Therapy. Journal of the American Academy of Audiology. 17(2):104-132, 2006.

**Jastreboff, P.J., Jastreboff, M.M. Tinnitus Retraining Therapy: A Different View of Tinnitus. J Oto-Rhino-Laringology, 68:23-30, 2006. Jastreboff, P.J. and Jastreboff, M.M. Theory and treatment if tinnitus and decreased sound tolerance. In: Clinical Otology. 3rd edition. eds G.B. Huges, M.L Pensak, Thieme, New York, Stuttgart, Ch 36: 487-497, 2007.

**Jastreboff, P.J. Tinnitus Retraining Therapy. In: Tinnitus: Pathophysiology and Treatment. eds. B Langguth, G. Hajak, T. Kleinjung, A. Cacace, A. Moller, Elsevier, Ch 40: 415-423, 2007.

**Jastreboff, P.J., Jastreboff, M.M. The Role of Hearing Aids in Tinnitus Management. In: Hearing Aid Dispensing for the Otolaryngologist. in press

Pawel J. Jastreboff, PhD, ScD, MBA, is the professor and director of the Tinnitus and Hyperacusis Center, Department of Otolaryngology, Emory University School of Medicine. Learn more at www.tinnitus-pjj.com.

Douglas L. Beck AuD, Board Certified in Audiology, is the Web Content Editor for the American Academy of Audiology.