Tinnitus, Cognitive Behavioural Therapy, and Extended Bandwidth Hearing Aids: Interview with Faye Hopkins
Douglas L. Beck, AuD, spoke with Faye Hopkins, and audiologist and adult services team leader, audiology services, at the First Community Health and Care CIC, at Crawley Hospital, West Sussex, National Health Services in the United Kingdom.
Academy: Hi, Faye, nice to chat with you again.
Hopkins: Hi, Doug, really good to speak with you again!
Academy: Faye, I recall you had a very interesting tinnitus patient we discussed mid-2012 or so, and now that things are apparently back on track for this gentleman, I thought it would be a good case to share with our readers.
Hopkins: Sure, Doug, happy to help.
Academy: Okay, so if you don't mind, please tell us the story, and let's start with the case history.
Hopkins: Well, the gentleman is a 62-year-old maintenance worker. He first came to our audiology service as a "walk-in" patient in August 2011. We'll call him Robert (not his real name). Robert had essentially normal hearing through about 5000 Hz bilaterally, and then a mild-to-moderate sensorinerual high-frequency hearing loss.
When we first saw him, he did report tinnitus in the left ear and he was apparently fine with it. Soon after that (November 2011) he returned to our clinic and saw one of my colleagues. Robert reported a probable "viral" illness, which was the tipping point that apparently exacerbated his tinnitus. That is, Robert reports his tinnitus suddenly became somewhat unbearable. He reported no additional or unusual noise exposure, no additional hearing loss, no head trauma or other otological issues. He was very clear that his tinnitus had increased substantially after the viral illness.
Academy: And so he went to his general practitioner (GP) before seeing your colleague?
Hopkins: Yes, Robert went to see his GP and he apparently told Robert to "learn to live with it." That "sage advice" was supposed to manage Robert and sort it all out.
Academy: And that's the part where I have to jump in! I personally believe when a licensed health-care professional tells a desperate tinnitus patient (or even a non-desperate tinnitus patient) he has to "learn to live with it," that's borderline malpractice and additionally, it usually indicates the professional hasn't read anything about tinnitus management in the last few decades! Of course, I readily admit, perhaps that's just my own bias and opinion, but the fact of the matter (as can easily be seen in the contemporary literature) is tinnitus patients can be taught to better manage their tinnitus quite effectively in the majority of cases, perhaps 75 to 90 percent of the time.
Hopkins: Yes, I remember you lectured on tinnitus at the British Academy of Audiology (BAA) meeting a year or two ago, and that actually got me thinking—there's quite a bit we can do to help!
Academy: Okay, climbing off my soap box...so then, after Robert was told to learn to live with it, what happened?
Hopkins: Well, he reported to my colleague what the GP had said and now he was really suffering. He reported feeling depressed and overwhelmed, he wasn't sleeping well and he felt incapable of working. In fact, he mentioned he had a holiday coming up in a few days and he felt unable to go because he was so stressed out from his tinnitus. He used the phrase "at his wit's end" and he said he felt "abandoned."
So my colleague felt that she certainly needed to try to help him manage and adapt to his tinnitus, and the first thing she tried was fitting him with a left ear open-fit hearing aid. Things seemed to have gone okay and he learned to use it, and we didn't hear from him for a few days. As it turns out, he was in absolute distress. My colleague told me about Robert and I tried to follow-up to see how he was doing. I couldn't get him on the phone, but I did manage to speak with his wife. She told me Robert had spoken with the crisis line and he had been taken into a "safe house" because he was indeed, suicidal.
Academy: And to be clear, a "safe house" is a psychiatric unit?
Hopkins: Yes, that's right. Of course, there are differences and variations, but yes, more-or-less sending him to the safe house was to keep him safe while he was under psychiatric care. So he was in the safe house for a week or so, and he was seeing the psychiatrist and was placed on anti-psychotic and anti-depressant medications. I saw him a few weeks later. Robert mentioned he was perseverating on the words of the GP, that nothing could be done, which seemed to me to be increasing his desperation and frustration. Further, by the time I saw him, he had also been seen by an ENT specialist who told him "Go away and get used to it!" So then, I saw him in the clinic and I did a full tinnitus assessment with him.
Academy: And this had not been done before?
Hopkins: No. This was his first full and formal tinnitus assessment.
Academy: Please tell us what you found?
Hopkins: He had experienced tinnitus for 20 years or so, and again, the tinnitus hadn't really bothered him very much, until he experienced the virus over the summer of 2011 and his tinnitus became substantially worse. He reported along with the virus he was a bit dizzy and out of sorts, but he had not experienced true vertigo. I repeated his hearing test that was essentially unchanged and I did a tinnitus matching, which showed he was perceiving tinnitus at about 5000 Hz, at about 10 dB SL (or so).
Academy: And that's very consistent with typical tinnitus patient experiences. Generally, tinnitus patients experience tinnitus in the high frequencies, and 5000 Hz is a very common spectral representation of tinnitus.
Hopkins: Right. And so I spent about an hour and 45 minutes with him chatting about tinnitus, doing the tests, and talking about coping strategies and possible emotional and acoustic tinnitus triggers. He was very heavily medicated and rather vacant. He wanted a pill to make it all go away...so he was hearing me, but he didn't really seem to have the ability to totally grasp the discussion. Of course, I recognized that at the time and so I did a slight tune-up and reprogramming of his hearing aids and arranged to see him again (30 days later) when he would be more aware and better able to participate in the discussion.
Academy: So then another month passed and what happened?
Hopkins: At this meeting, we reviewed quite a bit and spoke at length about habituation and his potential tinnitus triggers and different relaxation techniques, as well as masking sounds like music and other masking devices. Robert was still under psychiatric care and he hadn't really progressed very much from our last meeting. He told me he and a colleague had worked together for 20 years, his marriage was good and solid, and really, I couldn't find any clear-cut incident or issue besides the virus. And I should note, we often see tinnitus patients and we usually are very successful treating them with hearing aids or perhaps combined hearing aid/tinnitus devices. So this case was baffling for all of us.
As it progressed, a few months passed and I fit him with a white noise generator and his meds were being reduced. Nonetheless, he was still perseverating on the words of the GP and the ENT and he was still un-accepting of habituation. So over the next month or two we explored more of his hearing and noise and tinnitus background and management options and why he should use a noise generator and relaxation techniques. We covered many of the same things many times, but that's what he needed to do. Of course, I gave him material to read and he referred to those as is "bible." By January 2012, he seemed much better and he was off the medications. He also was much more aware of his surroundings and more engaged in the consultation. And, fortunately, he was appreciative of the "safety net" he and I had built through all the time we spent together. His understanding of his tinnitus seemed to be offering him some relief. In fact he said to me, when he feels his tinnitus is getting the better of him, he would go back and read through the materials and he found that helpful.
And by that time (January 2012) Robert had also gone to a Specialist Center, where he received Tinnitus Retraining Therapy (TRT) and Cognitive Behavioural Therapy (CBT). He had mixed progress and he felt frustrated at having to complete the Tinnitus Handicap Inventory (THI) at each visit. He told me he was also quite disappointed when told his treatment period was over, although he was given the opportunity to schedule additional ad-hoc treatments. Robert reported to me that later in 2012 he was experiencing his "bad thoughts" and was feeling "suicidal and out of control." His tinnitus had started to appear in the right ear, too, and he was experiencing it centrally as well. He actually had the Tinnitus Handicap Inventory (THI) in my office at that time and he scored an 88.
Academy: That would be a Grade Five, catastrophic handicap.
Hopkins: Right. And by that time, this had been going on for more than a year and that's when you and I spoke about Robert and we decided to try fitting him with extended bandwidth hearing aids bilaterally. We also re-visited relaxation techniques and the use of a bedside sound generator at night. After that point, his sleep patterns improved and he seemed to start showing real improvement. I saw him again in February 2013, and he had made significant progress. And so things are going reasonably well at this time (April 2013) and he hasn't expressed any suicidal thoughts. He is wearing the hearing aids and he has said there are many times at work where he does forget about the hearing aids and the tinnitus, and he seems to be habituating very slowly, but the stress and anxiety have decreased and his sleep and relationships have improved. He had started a new course of CBT at a new center.
Academy: And so it was a very long and very difficult habituation, but it seems to be working very well?
Hopkins: Yes, and this was to us, an absolutely difficult, challenging and complex case, but the overwhelming lesson learned was that it's best to not tell a patient there's nothing that can be done for tinnitus! One must be realistic and provide realistic expectations, and one must stay in touch with the patients based on their needs, and yes, the combination of time, extended bandwidth hearing aids, and CBT seemed to have eventually really helped Robert get back to his regularly scheduled life!
I should add that from my perspective, it really helped that myself and his CBT had contact, which meant we could complement each other's treatment with Robert, rather than Robert receiving mixed advice from different clinicians. I saw him for follow-up again recently and he was a completely different man sitting in front of me.
Academy: Thanks so much, Faye, this is a great case study in tinnitus, perseverance, and the fact that each tinnitus patient is an individual and there's just not a clear-cut approach that works for each patient. With time, knowledge, and experience, we can absolutely help the vast majority of tinnitus patients.
Hopkins: Thank you, Doug. I'm glad we were able to help and I'm hopeful Robert is on the route to a better life and a better listening experience!
Faye Hopkins, is an audiologist and adult services team leader, audiology services, with First Community Health and Care CIC, at Crawley Hospital, West Sussex, National Health Services in the United Kingdom.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.