Volume 11, Number 3, September 1986 THE AMERICAN TINNITUS ASSOCIATION

E. Robert Libby

COPING WITH TINNITUS

Tinnitus is rarely cured. For some, tinnitus is something that must be faced every day. It can restrict the ability to enjoy life, even to think straight. It can become a confusion of psychological and physcial problems that often can not be easily solved. It usually requires lifelong management with the exploration of all possible avenues including hearing aids, tinnitus maskers, the use of drugs, electrical stimulation and diet control. Often management problems for tinnitus relief can not provide the daily reinforcement and support many tinnitus patients appear to need. There is growing interest in psychological methods of tinnitus control such as biofeedback and systematic relaxation procedures which help the subject to cope with the stress, tension and anxiety of the tinnitus (House, 1978), (Svihovec and Carmen, 1982). This approach is be-

ing applied with considerable success to tinnitus patients with emphasis being placed on treating the patient's reaction to tinnitus rather than the tinnitus itself. (Sweetow, 1986), (Hallam and Jakes, 1986). For many subjects, the tinnitus is real enough and often intractable. Therefore the goal is to help modify what we can modify, and that is the patient's perception of the tinnitus rather than focusing entirely on the physical loudness of the tinnitus. Subjects with tinnitus are being taught ways to relax as part of a total tinnitus treatment which may include hearing aids, tinnitus maskers and progressive muscle relaxation based on principles of conditioning . Relaxation pro cedures are usually easily mastered and can be perform ed daily in the patient' s home environment. Research has demonstrated that the relaxation response can release muscle tension, lower blood pressure, and slow heart and breath rates. The simple act of becoming relaxed systematically can often have surprising health benefits and can often go far in relieving the stress and tension of tinnitus. Hallam and Jakes in the January 1986 ATA Newsletter reported that approximately one third of their chronic tin nitus subjects reported substantial relief in terms of annoyance and distress with the use of relaxation techniques. Relaxation is being used successfully in treating other chronic conditions such as the lessening of severe palo. chronic migraine. insomnia and hypertension. The benefits seem to come from the physiology of relaxation rather than mere suggestion. Simply telling a person to relax is not enough. Regular use of relaxation exercises are required before significant benefit may occur.

Metronome Conditioned Relaxation (MCR) In 1973, Dr. John Paul Brady, who was at that time Chairman of the Department of Psychiatry at the University of Pennsylvania Medical School, developed a relaxation method which he named Metronome Conditioned Relaxation (MCR). The technique has been used successfully for many years for the relief of chronic pain, insomnia, tension headaches and any other conditions. MCR has now been adapted specifically for the treatment of tinnitus. Sweetow (1986), Sandlin (1986) and Altshuler (1986) have reported positive benefits as part of a total approach which can also include hearing aids and tinnitus

(Coping, continued)

maskers. Many mild to moderate tinnitus subjects can often obtain substantial relief from the anxiety and stress by the use of the MCR program alone. The first section of the program deals with information to help the patient understand more about the realities of tinnitus and acquaints the listener with some strategies to cope with the tinnitus associated problems of stress and tension. It is pointed out that the relief the patient is seeking may have to come largely from a psychological approach. Despite the reality of the tinnitus it is emphasized that tinnitus is influenced by many things that are not physical, but mental, and those we can modify and deal with. Basically the tools and the power to minimize the tinnitus is returned to the patient. The purpose is to help the patient develop a lifestyle where the tinnitus is neutralized and not an annoyance. The second section teaches the patient the relaxation skills of Metronome Conditioned Relaxation. MCR is based on principles of deep muscular relaxation which is an active component of systematic desensitization therapy. Most behavior therapists induce relaxation in their patients by an abbreviated version of a technique originally described by Jacobson (1938), called progressive relaxation. MCR is a unique way to facilitate deep muscular relaxation which is efficient, reliable and convenient. A tape recorded program is available which will allow the subject to practice MCR daily at home. The MCR program is designed to induce two interrelated kinds of relaxation - physical and psychological. The early part of the tape focuses on physical relaxation attaining a state of profound relaxation. This is facilitated by the rhythmic beats of a soft metronome which are paired with instructions and suggestions to enter a state of calm and tranquility. When using this tape it is essential to be in a comfortable position in which no effort is required to maintain posture. Most persons find it best to be lying on their backs on a bed, couch, or in a reclining chair. The tape lasts 30 minutes. After a week or so of experience relaxing with the tape, for the full 30 minutes, 10-20 minutes of the tape may be sufficient. Regular practice is essential for the best results. For the first week relaxation is practiced with the tape at least once, but preferably twice daily. After this, one daily session should suffice. After the second week it is often possible to skip the first 6 minutes of the tape. The program also consists of two additional masking tapes which have demonstrated substantial benefit and which can be used whenever the patient feels the need for additional relief. They consist of (1) a recording of a babbling brook enhanced by electronic filtering, (2) a recording of tropical sounds consisting of a peaceful island stream complete with birds, crickets and bullfrogs, (3) a unique computer generated chorus of sounds accompanied by a gentle breeze. These record~ ings can be used to induce sleep or as a soothing backdrop for activity and can be played on a simple portable cassette player.

Conclusion In conclusion, there appears to be a place in tinnitus therapy for the use of systematic relaxation techniques which in union with hearing aids and maskers often bring substantial rel ief to the tinnitus sufferer. Many patients with mild to moderate cases of tinnitus can often obtain substantial relief from anxiety and stress by the use of the relaxation program alone. The advantage of the MCR tape recorded program is that the patient can practice relaxation daily at home. Patients may say, "I still have the sensation of tinnitus. The sounds are sti ll there, but I'm not nearly so aware of them." If the sound of tinnitus is still there, but the patient is not aware of it, is it indeed there? I'll leave that question to the philosophers. (Editor's note: Relaxation therapy should not be selfinitiated by people who are receiving psychological counseling. Please, if you are under the care of a psychiatrist or psychologist, consult them first before embarking on any additional programs.
References Brady, J.P., Metronome Conditioned Relaxation - A New Behavioral Procedure. British Journal of Psychiatry (1973) 122, 729-30. Hallam, R.S. & Jakes, S.C. American Tinnitus Association Newsletter, Jan. 1986. House, J., Treatment of severe tinnitus with biofeedback training. Laryngoscope 88 (3}, 1978. Jacobson, E. (1938) Progressive Relaxation. Chicago: Univ. of Chicago Press. Svihovec, D. & Carmen, R. in Tinnitus and its management. C. Thomas: Springfield, IL 1984. Sweetow, R., 1986 - in press.

CURRENT INVESTIGATIONS FOR THE RELIEF OF TINNITUS - PART II

(Editor's note: Readers will recall that Dr. Vernon was the first recipient of the Hocks Memorial Award. This series of articles takes the place of an acceptance speech, and provides us with an update on tinnitus research.) This is the second of a three part article on tinnitus research projects. Part I was devoted to four different studies utilizing electrical stimulation. In Part II two more studies using electrical stimuli will be reviewed before turning to other techniques. 5. Brusls and Loennecken, working in Germany, have tested a tinnitus treatment combining DC electrical energy and lidocaine; another example of combined elements. Lidocaine is a commercially available local anesthetic which is considered to be very safe. It is lidocaine, you will recall, which, when injected intravenously, gives short, temporary relief of tinnitus for most patients (abqut 88% ). Brusis and Loennecken used lidocaine to anesthetize the eardrum. They did not inject the lidocaine
(cont. p. 3)

(Investigations, cont. from page 2)

but rather used a process known as iontophoresis. Iontophoresis is a process whereby chemical ions can be pushed painlessly through the skin or the eardrum by the repelling action of direct current (DC electricity). Iontophoresis is a routine method of painlessly anesthetizing the eardrum which was developed at Kresge Laboratory. Brusis and Lennecken repeated this procedure daily on tinnitus patients for 5 or 6 sessions. According to these German investigators, there were 31 patients out of a total of 50 (62%) who obtained relief of their tinnitus. We are not told how long the relief lasted, but it is implied that the period of relief was not inconsequential. Recently, using the technique of Brusis and Loennecken, we have tested a small number of American patients, and so far have had no satisfactory results. The work must continue. 6. Frayssee and Lazorthes, working in France, have driven an electrode through the eardrum so that its tip came to rest on the wall of the inner ear. As with the Theraband unit, these investigators utilized a highfrequency carrier wave upon which was impressed an electrical signal which constantly varied from 150 Hz through 1500 Hz. To date, they have only treated 5 patients, all of whom were deaf, but in 4 of the 5 they found a positive result. In one patient, the relief of tinnitus lasted 18 months after only one treatment! In one patient, the relief lasted one month and in the remaining two patients the relief endured only so long as the electrical current was ongoing. Encouraged by these results, Frayssee and Lazorthes now plan a larger study. At this point, Bob Hocks, we now turn away from electrical attempts to other procedures aimed at the suppression of tinnitus. 7. Amino-oxyacetic Acid (AOAA). Paul Guth and his associates in New Orleans have been working with AOAA as a relief treatment for tinnitus. AOAA has previously been credited with producing a reversible loss of hearing sensitivity. Because the drug appears to have an inner ear site of action, Guth reasoned it might be helpful for those forms of tinnitus associated with cochlear damage. In a pilot study, 10 patients were treated with AOAA and 3 reported a lessening of tinnitus. This is a small sample of patients, but Guth did a double-blind, crossover placebo study; thus even a 30% success rate is worthy of additional study. 8. Tocainlde. Recall the highly positive, although temporary, effects of intravenous injections of lidocaine. Tocainide is an oral medication which is chemically very close to lidocaine. Brummett and his team working at Kresge Laboratory studied the effects of tocainide on 21 patients in a double-blind, crossover, placebo study. Only one patient received any benefit to his tinnitus, and he estimated that to be about 50%. More importantly, the side effects were so severe that only 8 of the 21 completed the full study. We have concluded that tocainide is probably not worth additional study. 9. Glutamic Acid. Ehrenberger and Brix, working in Austria, have claimed control of tinnitus by intravenous injections of Glutamic Acid and the diethylester of glutamic acid, which has produced a long-term suppression of tinnitus. Sixty patients were tested and at one point there were 20 who were free of tinnitus anywhere from three to 18 months! There were 19 with low-level tin-

nitus who obtained no benefit from the treatment. While the precise results are a bit difficult to decipher, it is nevertheless the case that such long-term relief is worthy of additional study, even if it only occurs in a relatively low percentage of cases. 10. Xanax. Xanax is an antianxiety drug which is effective in combatting mental states of anxiety. From time to time, some tinnitus patierats have been treated for anxiety by Xanax and have then found that their tinnitus was reduced. We heard enough of these reports to cause Bob Johnson and Bob Brummet1 of our laboratory to do a pilot study. They selected 10 patients from the Tinnitus Clinic files who agreed to serve as guinea pigs. The treatment schedule lasted two weeks, and of the 10 patients 5 reported relief. Measurement of the loudness of the tinnitus for these 5 patients also revealed a reduction in their loudness measures. Although no one reported a disappearance of tinnitus for those experiencing relief, it was a reduction by at least 50%. Is there any patient with severe tinnitus who would not welcome a 50% reduction in their tinnitus? These data are sufficiently encouraging that a full-scale, carefully controlled study of Xanax will be done. There was one point upon which all patients were in agreement - they enjoyed restful, uninterrupted sleep during the course of the medication . We all dream of a pill for tinnitus, but more realistically we should also remember that pills have side effects, of which addiction is one. Nevertheless, it may be possible to use Xanax to break acute attacks of severe tinnitus or to help in the search for safer drugs. 11.The Tinnitus Inhibitor. Colin Kemp, an engineer working in Australia, markets a unit he calls the Tinnitus Inhibitor. It's a pocket-sized, battery-operated device which offers the production of a variety of pure tones ranging from about 100Hz through 10,000 Hz. To use the device, the patient adjusts the tone control until they find that tone which most nearly matches the pitch of their tinnitus. They then introduce that tone to the tinnitus ear at an intensity which masks the tinnitus and for a short period of time. Cessation of the masking tone usually finds the tinnitus to be temporary reduced for a brief period. At our Tinnitus Clinic, we call this phenomenon Residual Inhibition and routinely test all patients for it. Residual inhibition comes in many forms, but in one form or another we find it in nearly 89% of patients. Kemp's idea is to cause the patient to accumulate residual inhibition by repeated treatments so as to finally obtain a significant period of relief. One can imagine, for example, using residual inhibition to help induce sleep. In a personal communication from Kemp, he indicated that he sold the Tinnitus Inhibitor on a partial money-back guarantee ($30 of $50 cost could be returned), and went on to say that of the several thousand he has sold, only 18% have been returned. I do not think that means a success rate of 82%. Most likely, it means that some patients enjoy a demonstration of control over their tinnitus, while for others it is of value to have a concrete means whereby their tinnitus can be demonstrated. I know I carry one of Colin Kemp's Inhibitors wherever I travel for the purpose of demonstrating various kinds of tinnitus. 1 think Mr. Kemp may have something here. Does residual inhibition accumulate over time? Mr. Kemp's unit should be rigorously tested with a large sample of tinnitus patients. That's what is needed. [End of Part II] JAV.

TRIBUTES

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In Honor Of
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THANK YOU, THANK YOU, THANK YOU

We have received nearly 12,000 responses to the survey that was included in the last ATA NEWSLETTER. Survey results will be reported in a future issue. Our task now is to code and enter the data for computer analysis. That project is underway and already requires increased expenditures. We are most gratefu l to those of you who enclosed annual contributions along with your survey. Those funds have enabled us to carry on and pay the substantial expenses of answering both the "Ann Landers" and the more recent "Dear Abby" mail. We want to continue to help tinnitus sufferers by funding research and providing you with this Newslette r. Please help us by sending your tax-deductible contribution today.

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ATTENTION ATA REFERRAL CLINICS

DEAR FEDERAL EMPLOYEES: CIVILIAN, MILITARY AND POSTAL

ATA is a participant in your combined federal giving campaign. We are members of the National Voluntary Health Agencies and are fully qualified to receive all or part of your annual charitable gift. We hope that you will think of us when it comes time to fill out your pledge card for the fall campaign. While we welcome your direct gift to ATAwe are cognizant of the fact that many of you like to make all of your charitable gifts through payroll withholding. ATA is not notified of your individual gift through the CFC so we are not able to thank you personally, but your gift is sincerely appreciated. You must notify us, however, if you want to continue to receive the ATA NEWSLETTER. Ordinarily your individual record would show no donations to ATA but we can flag your record as a CFC giver if you will inform us of your CFC gift. Thank you for helping support ATA through the CFC. 6

You should find your telephone quieting down a little now that ATA's mailbox is a bit less stuffed with inquiries from patients. We have sent out about 115,000 referral lists in 1986. There are presently about 500 of you whose names appear on those lists, so we must assume that your patient load has increased substantially as a result of our referrals. A number of patients have contacted us to tell us that some of you are no longer at the address given-- or that you don't answer the telephone-- or that the clinician listed at a particular facility has long since moved away. THIS WON'T DO! We are trying to di rect patients to people who can help them. You must let us know when there is a change of address or personnel in your facility. Kindly fill in the change of address notice below and send it along with your annual contribution to: ATA, Box 5, Portland, OR 97202. Thank you. NAME
(Please include correct title)

CLINIC OR BUSINESS NAME _ _ __ _ _ __ STREET CITY _ _ _ _ STATE _ _ _ _....... IP _ __ _ TELEPHONE ('-----'-)_ _ _ _ _ _ _ _ __

WHAT PEOPtE TELL US

DID YOU KNOW THAT . ..

(Editor's note: Sally Benson and Betty Mathis volunteer regularly for ATA projects. Their help is valuable and very much appreciated. Tinnitus is a sympton of hearing dysfunction and can be caused by anything that might damage the auditory system. The following list is not intended to be inclusive or statistically accurate. It is presented to demonstrate the variety of causes for tinnitus. Here are some things that people say started their head noise: Hearing loss Military service Noise Accidents (all kinds} Menieres syndrome Flu Ear infection Flying Instant hearing loss Dental work Hereditary Head cold Kidney infection Sinus infection Childbirth Mumps Swimming Rheumatic fever Measles Scarlet fever Diptheria Neck exercise Sneeze Hit by lightning

Tinnitus severely disrupts the lives of more than 10 million Americans yet it is a condition about which there are many unanswered questions. The American Tinnitus Association believes that it is essential to promote multidisciplinary research in order to find ways to relieve tinnitus distress. Meanwhile, knowledge is the best weapon for coping with tinnitus. You are encouraged to participate in our self-help group program. If there is not a group near you we will be happy to help you start one. . . . Write to us for further information.

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The ATA Newsletter is published quarterly and mailed directly to ATA contributors and hearing health care professionals throughout the world. Circulation is 140,000. Editor: Gloria E. Reich Circulation Manager: Patricia Daggett Articles submitted for possible publication should be typewritten, double-spaced, on one side of regular 8 Y2 x 11 " paper. Preferred length is 1000 words or less. Articles are selected for editing and publication with the help of the ATA scientific advisory board. For more information write to: AMERICAN TINNITUS ASOCIATION P.O. Box 5, Portland, OR 97207 A private non-profi t corporation under the laws of Oregon SCIENTIFIC ADVISORS: Jack D. Clemis, M.D., Illinois David D. DeWeese, M.D., Oregon John R. Emmett, M.D., Tennessee Chris B. Foster, M.D., California Richard L. Goode, M.D., California Howard P. House, M.D., California Robert M. Johnson, Ph.D., Oregon Gale W. Miller, M.D., Ohio J. Gail Neely, M.D., Oklahoma Jerry Northern, Ph.D., Colorado George F. Reed, M.D., New York Robert E. Sandlin, Ph.D., California Mansfield Smith, M.D., California Abraham Shulman, M.D., New York Francis A. Sooy, M.D., California Harold G. Tabb, M.D., Louisiana HONORARY DIRECTORS: Del Clawson, U.S. House Rep. Ret. CA U.S. Senator Mark Hatfield, Oregon LEGAL COUNSEL: Henry Breithaupt, Steel, Rives, Boley, Fraser and Wyse BOARD OF DIRECTORS: Frederick J. Artz, Washington Robert M. Johnson, Chmn. pro-tem Thomas Wissbaum, C.P.A., Oregon Gloria E. Reich, Exec. Dir., Oregon
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Remember to send your annual contribution today. In order to save the additional costs of printing and postage there will be no direct billing for 1986. We do need and appreciate your support. ATA receives all of its funding from private donations. We are not affiliated with any university or government agency or United Way. Just as we must accept responsibility for caring for our tinnitus we must accept personal responsibility for finding its cure. Everyone can help with a donation. Please join me and thousands of others around the world who are working together to FIGHT TINNITUS!

THIRD INTERNATIONAL TINNITUS SEMINAR June 11-13, 1987, Muenster, W. Germany The organizing committee headed by chairman, Harald Feldmann, M.D. are planning a meeting of scientists who will be presenting papers on subjects relating to tinnitus research. Topics will include : - etiology and pathophysiology of tinnitus - models of tinnitus - acoustic emissions - psychoacoustic masking phenomena -evaluation of tinnitus parameters - diagnosis and classification - treatment by maskers - electrical stimulation - treatment by drugs - biofeedback -surgical treatment Scientists desiring further information about the conference should make inquiry of: Secretariate ENT Department, Univ. of Muenster, Kardinai-Von-Galen-Ring 10, 4400 Muenster, WEST GERMANY

TINNITUS BOOK NOW AVAILABLE The American Tinnitus Association offers the Proceedings of the 2nd International Tinnitus Seminar, New York, NY, June 10-12, 1983. 62 Papers - 323 pages MECHANICS: facts & theories DIAGNOSIS TREATMENT: psychological medical surgical suppression with electrical stimulation ORDER NOW - SPECIAL CLOSEOUT PRICE $17.50 U.S. FUNDS POSTPAID IN THE U.S. ADD $2.50 U.S. FUNDS FOR POSTAGE OUTSIDE U.S. PREPAID ORDERS ONLY: check to: ATA. P.O. Box 5, Portland, OR 97207

Published by the AMERICAN TINNITUS ASSOCIATION P.O. Box 5, Portland, OR 97207 A private non-profit corporation under the laws of Oregon

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