Mindfulness-based interventions have recently gained popularity in treating and managing tinnitus-related symptoms, much as in other neurological and psychological conditions. Mindfulness-based therapies refer to a wide range of interventions where an individual’s “mindfulness” practice plays a prominent role.
Mindfulness, in this context, is defined as “paying attention in a particular way; on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 1994). Mindfulness-based interventions have long been adopted by clinical psychologists to treat affective disorders, such as intractable depression and anxiety.
The two most popular mindfulness-based programs are mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). MBSR is an eight-week course of skill-based instruction and practice in mindfulness meditation, coupled with psychoeducation on stress and emotion (Bishop, 2002). An individual practices daily meditation outside the group-class setting, but the class allows for discussions designed to help enhance these meditative practices and mindful awareness (Brantley, 2005).
MBCT incorporates mindfulness exercises with aspects of cognitive behavioral therapy (CBT). Here, as in MBSR, the format consists of an eight-week course of study, with weekly two-hour classes consisting of instruction and practice in mindfulness, use of mindfulness audio recordings between classes, and weekly readings from a workbook (Teasdale et al, 2014).
The goal of such experiential mindfulness-based interventions is to teach participants to develop a new, more resilient relationship with thoughts, feelings, body sensations and, specifically, a new relationship with distress. The cognitive therapy component seeks to shift awareness of thoughts and a person’s relationship to these thoughts (Teasdale et al, 2000) to a healthier outlook.
A key motivation for employing MBCT as a potential treatment for tinnitus is also the observation that CBT is reasonably effective in treating distressing tinnitus (Cima et al, 2014; Hesser et al, 2011; Martinez-Devesa et al, 2010).
Summary of Research
A recent large-scale study by McKenna et al (2018) provided the best evidence of the efficacy of using MBCT in treating tinnitus. In this study, 182 patients in a tinnitus clinic showed significant and robust improvements of tinnitus-related handicap and associated improvements in tinnitus acceptance and measures of mindfulness.
Apart from MBCT and MBSR, other types of mindfulness-based programs have been undertaken to help with tinnitus. Gans and colleagues (2014, 2015) created a version of mindfulness-based instruction called mindfulness-based tinnitus stress reduction (MBTSR) specifically designed to help those trying to cope with tinnitus. This modified the original MBSR program by including elements of tinnitus-related psychoeducation and additional training regarding awareness of sounds.
In these studies, the researchers found a significant reduction in tinnitus severity scores that was maintained and even enhanced at a 12-month follow-up assessment (Gans et al, 2015). Eighty-five percent of subjects reported continued mindfulness practice during the follow-up period. This suggests that mindfulness practice may be particularly effective when incorporated as a lifestyle change.
Longitudinal studies within the same group of patients provide a limited type of evidence of efficacy. It is unknown whether reductions in tinnitus handicap would be evident with continued practice or how mindfulness-based treatments may compare to standard tinnitus treatments. Randomized controlled trials are needed to answer these questions.
Relaxation therapy has been used as the alternate therapy in several randomized controlled trials of mindfulness-based interventions. In the first such study (Philippot et al, 2012), psychoeducation was provided to all participants before they were randomly assigned to receive either MBCT or relaxation training. It was found that, while psychoeducation significantly reduced tinnitus distress, those treatment gains were preserved better through MBCT than relaxation therapy.
In a second randomized controlled trial, McKenna et al (2017) showed that, when compared to relaxation therapy, MBCT can be more effective in reducing tinnitus severity, while both therapies showed significant improvements in psychological distress, anxiety, depression, and tinnitus loudness and severity. A separate study (Arif et al, 2017) also showed a significant improvement for mindfulness meditation compared to relaxation therapy.
Non-invasive brain-imaging studies have begun to delineate the effect of mindfulness-based therapies on brain networks in patients with tinnitus. In the first brain-imaging study on tinnitus, Roland et al (2015) showed an effect of MBSR on the attention network, but not on other neural networks.
In our recently published study (Husain et al, 2019), 15 participants underwent audiological and behavioral screening, establishing a baseline prior to treatment, in addition to three subsequent assessments: pre-intervention, post-intervention, and follow-up (eight weeks after completion of training). Of these, eight also underwent three magnetic resonance imaging (MRI) tests, at pre- and post-intervention and at an eight-month follow-up (Zimmerman et al, 2019).
In terms of self-reported questionnaires, we found both statistically and clinically significant reductions in tinnitus distress over the course of the intervention and during the follow-up period. We found changes affecting several neural networks, but only a few neural networks showed changes that could be correlated with a decline in tinnitus handicap: the dorsal attention network, the front-parietal network, and the functional connections from the amygdala (part of the limbic emotion-processing system).
These results point to a mostly differentiated landscape of functional brain measures related to tinnitus severity, on the one hand, and mindfulness-based therapy on the other. However, overlapping results of decreased amygdala connectivity with parietal areas and the negative correlation between amygdala-parietal connectivity and tinnitus handicap is suggestive of a brain-imaging marker of successful treatment.
Gray-matter change as a result of tinnitus treatment has been reported in other intervention studies (Krick et al, 2015; Poeppl et al, 2018).
In our MBCT study (Husain et al, 2019), we observed that gray-matter changes in occipital and cingulate regions were correlated with declines in tinnitus handicap.
One of the advantages of mindfulness-based therapies is that they can be accommodated readily to suit individual preference. Daily practice during the more intensive period of the training varies by individuals, as does their continued adoption of the meditative practices after the completion of the training.
Nevertheless, few tinnitus studies have explored this aspect of mindfulness, beyond assessing changes in tinnitus-related severity. Smartphone-based apps, which facilitate meditative practices (e.g., Headspace, Calm) and those that incorporate meditative practices as part of general tinnitus-related apps (e.g., Resound Relief) are being adopted by tinnitus patients.
However, further research should be conducted about the usage of such apps worldwide among tinnitus patients and the benefit gained from such usage. Research using such apps or internet-delivery methods may also assist with a better understanding of the “dosage” of such psychology-based interventions and may lead to individualized treatment plans.
Mindfulness-based therapies provide an augmentative and alternative standard of care for audiologists and otologists in managing tinnitus-related distress. Thus, they can be added to existing clinical protocols focused on sound-based therapies (both amplification and sound maskers/generators). These interventions should be done in conjunction with a mental health provider.
However, future research studies are needed to gain a better understanding of how mindfulness-based therapies help in managing tinnitus symptoms and to aid with the standardization of protocols across clinics.
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