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Tinnitus in Context: A Contemporary Contextual Behavioral Approach
Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Tinnitus is the experience of sounds in the ears without any external auditory source and is a common, debilitating, chronic symptom for which we have yet to develop sufficiently efficacious interventions. Cognitive behavioral therapy (CBT) has evolved over the last 20 years to become the most empirically supported treatment for treating the adverse effects of tinnitus. Nevertheless, a significant proportion of individuals do not benefit from CBT-based treatments. In addition, the theoretical underpinnings of the CBT-model are poorly developed, the relative efficacy of isolated procedures has not yet been demonstrated, and the mechanisms of therapeutic change are largely unknown. These significant limitations preclude scientific progression and, as a consequence, leave many individuals with tinnitus suffering.

To address some of these issues, a contextual multi-method, principle-focused inductive scientific strategy, based on pragmatic philosophy, was employed in the present thesis project. The overarching aim of the thesis was to explore the utility of a functional dimensional process in tinnitus: Experiential avoidance—experiential openness/acceptance (EA). EA is defined as the inclination to avoid or alter the frequency, duration, or intensity of unwanted internal sensations, including thoughts, feelings or physical sensations. The thesis is based on experimental work (Study II, VI), process and mediation studies (Study I, III, V), and on randomized controlled trials (Study III, IV).

Three main sets of findings supported the utility of EA in tinnitus. First, an acceptance-based treatment (i.e.,Acceptance and Commitment Therapy, ACT) was found to be effective in controlled trials. Study III demonstrated that face-to-face ACT was more effective than a wait-list control and a habituation-based sound therapy. Study IV showed that internet-delivered ACT was more effective than an active control condition (internet-discussion forum) and equally effective as an established internet-delivered CBT treatment. Second, processes research (Study I, III, V) showed that key postulated processes of change were linked to the specific technology of ACT and that these changes in processes were associated with therapeutic outcomes. Specifically, Study V found evidence to that decreases in suppression of thoughts and feelings over the course of treatment were uniquely associated with therapeutic gains in ACT as compared with CBT. Third, experimental manipulations of experiential avoidance and acceptance processes provided support to the underlying dimension (Study II, VI). That is, Study II, employing an experimental manipulation, found that controlling background sounds were associated with reduced cognitive efficiency and increased tinnitus interference over repeated experimental trials. In addition, in normal hearing participants, experimentally induced mindfulness counteracted reduced persistence in a mentally challenging task in the presence of a tinnitus-like sound stemming from initial effortful suppression of the same sound (Study VI). It is concluded that a principle-, contextual-focused approach to treatment development may represent an efficient strategy for scientific progression in the field of psychological treatments of tinnitus severity.

Abstract [sv]

Tinnitus är upplevelsen av ljud i frånvaro av en extern ljudkälla och är ett vanligt, långvarigt och svårbehandlat hälsotillstånd. Kognitiv beteendeterapi (KBT) har det starkaste forskningsstödet för att behandla de negativa konsekvenserna av tinnitus. Detta till trots svarar inte en stor andel på KBT-baserade behandlingar för tinnitus. Behandlingsutvecklingen av KBT försvåras som konsekvens av att teorier som behandlingen vilar på är dåligt utvecklade, effekten av isolerade tekniker har inte bevisats, och att förändringsmekanismer är till största del okända.

Föreliggande avhandling avsåg att adressera några av ovanstående problem genom att tillämpa en induktiv, flermetod, principstyrd vetenskaplig strategi baserad på pragmatisk kontextuell filosofi. Det övergripande syftet med avhandlingen var att undersöka användbarheten i en funktionell processdimension vid tinnitus: upplevelsemässigt undvikande—upplevelsemässig acceptans (EA). EA definieras som benägenheten att undvika eller förändra frekvensen, durationen eller intensiteten av icke-önskade inre sensationer som tankar, känslor och fysiologiska sensationer. Avhandlingen är baserad på experimentella studier (Studie II, VI), process och mediationsstudier (Studie I, III, V) och randomiserade kontrollerade studier (Studie III, IV).

Tre övergripande fynd bekräftade användbarheten av EA vid tinnitus. För det första kunde det påvisas i randomiserade, kontrollerade studier att en acceptans-baserad behandling (Acceptance and Commitment Therapy, ACT) hade effekt på tinnitusbesvär. Studie III fann stöd för att ACT var mer effektiv än en väntelistekontroll och en habitueringsfokuserad ljudterapi. Studie IV fann stöd för att internet-förmedlad ACT var mer effektiv än en aktiv kontrollbetingelse (internet-diskussionsforum) och lika effektiv som en etablerad internet-förmedlad KBT-behandling. För det andra kunde processforskning (Studie I, III, V) påvisa att teoretiskt viktiga processer var relaterade till specifika tekniker i ACT och att dessa processer var i sin tur associerade med behandlingsutfall. Exempelvis kunde Studie V styrka att minskning i individers benägenhet att tränga undan tankar och känslor i relation till tinnitus var unikt associerat med behandlingsutfall i ACT i jämfört med KBT. För det tredje påvisade experimentella manipulationer av acceptans- och undvikande-processer användbarheten av EA (Studie II, VI). Studie II fann stöd för att kontroll över maskeringsljud var associerad med minskad kognitiv prestationsförmåga och ökade besvära av tinnitus över upprepade experimentella manipulationer i jämfört med att inte ha kontroll över maskeringsljudet. Slutligen visade Studie VI att bland normalhörande kunde experimentellt inducerad mindfulness motverka minskad förmåga att hålla ut i en mentalt krävande uppgift i närvaro av ett tinnitusliknande ljud till följd av initial suppression av samma ljud. Den övergripande konklusionen av vetenskapliga arbeten som sammanfattas i avhandlingen var att en principstyrd och kontextuell vetenskaplig strategi kan vara en framkomlig väg för att utveckla psykologiska behandlingar för tinnitusbesvär.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 106 p.
Series
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 570Studies from the Swedish Institute for Disability Research, ISSN 1650-1128 ; 45
Keyword [en]
Tinnitus, acceptance, cognitive behavioral therapy, experiential avoidance, acceptance and commitment therapy
National Category
Applied Psychology
Identifiers
URN: urn:nbn:se:liu:diva-88416ISBN: 978-91-7519-701-2 (print)OAI: oai:DiVA.org:liu-88416DiVA: diva2:603412
Public defence
2013-03-15, I:101, Hus I, Campus Valla, Linköping University, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2013-02-15 Created: 2013-02-05 Last updated: 2014-11-28Bibliographically approved
List of papers
1. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress.
Open this publication in new window or tab >>Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress.
2009 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 47, no 6, 523-8 p.Article in journal (Refereed) Published
Abstract [en]

Cognitive-behavioral treatment (CBT) is considered to be an effective treatment of distress associated with tinnitus (perception of internal noises without any outer auditory stimulation), but the processes by which the therapy works remain unclear. Mindfulness and acceptance is receiving increased attention in the treatment literature for chronic medical conditions. However, few studies have examined these and related processes with behavioral or observer measures. In the present study 57 videotapes (a total of 1710min) from 19 clients who participated in a controlled trial of an acceptance-based treatment for tinnitus distress, were coded for frequency and peak level of verbal behaviors expressing either acceptance or cognitive defusion. Frequency of cognitive defusion behaviors and peak level of cognitive defusion as well as peak level of acceptance rated in Session 2, predicted symptom reduction 6 month following treatment. These relationships were not accounted for by the improvement that had occurred prior to the measurement point of the process variables. Moreover, prior symptom changes could not predict process variables rated later in therapy (after most of the improvement in therapy had occurred). Thus, clients' in-session acceptance and cognitive defusion behaviors appear to play an important role in the reduction of negative impact of tinnitus.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-18989 (URN)10.1016/j.brat.2009.02.002 (DOI)19268281 (PubMedID)
Available from: 2009-06-07 Created: 2009-06-07 Last updated: 2017-12-13Bibliographically approved
2. Consequences of Controlling Background Sounds: The Effect of Experiential Avoidance on Tinnitus Interference
Open this publication in new window or tab >>Consequences of Controlling Background Sounds: The Effect of Experiential Avoidance on Tinnitus Interference
2009 (English)In: REHABILITATION PSYCHOLOGY, ISSN 0090-5550, Vol. 54, no 4, 381-389 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Masking by the use of sounds has been one of the most commonly applied means of coping with tinnitus. The ability to control auditory stimulation represents a potentially important process involved in tinnitus masking strategies. Little is, however, known about the consequences of control on tinnitus experience. The present study investigated the effects of control of background sounds (type and loudness) on perceived intrusiveness of tinnitus and cognitive performance. Design: Using an experimental design with a series of trials, participants with clinically significant tinnitus (N = 35) were randomly assigned to I of 2 experimental manipulation conditions (control of sounds vs. no control of sounds). Measures: Self-reported tinnitus interference and the Digit-Symbol subtest served as dependent measures. Results: Latent growth curve modeling showed that individuals assigned to the condition with control exhibited faster growth rates on tinnitus interference (increased interference) and demonstrated slower rates of improvement on cognitive performance measures over trials compared to individuals assigned to the condition with no control. Conclusion: These results suggest that efforts to control tinnitus through sounds can be associated with increased disability in individuals with tinnitus.

Keyword
tinnitus, control, tinnitus interference, cognitive functioning, experiential avoidance
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-52818 (URN)10.1037/a0017565 (DOI)
Available from: 2010-01-12 Created: 2010-01-12 Last updated: 2014-11-28
3. Acceptance and Commitment Therapy versus Tinnitus Retraining Therapy in the treatment of tinnitus: A randomised controlled trial
Open this publication in new window or tab >>Acceptance and Commitment Therapy versus Tinnitus Retraining Therapy in the treatment of tinnitus: A randomised controlled trial
Show others...
2011 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 49, no 11, 737-747 p.Article in journal (Refereed) Published
Abstract [en]

The study compared the effects of Acceptance and Commitment Therapy (ACT) with Tinnitus Retraining Therapy (TRT) on tinnitus impact in a randomised controlled trial. Sixty-four normal hearing subjects with tinnitus were randomised to one of the active treatments or a wait-list control (WLC). The ACT treatment consisted of 10 weekly 60min sessions. The TRT treatment consisted of one 150min session, one 30min follow-up and continued daily use of wearable sound generators for a recommended period of at least 8h/day for 18 months. Assessments were made at baseline, 10 weeks, 6 months and 18 months. At 10 weeks, results showed a superior effect of ACT in comparison with the WLC regarding tinnitus impact (Cohen's d=1.04), problems with sleep and anxiety. The results were mediated by tinnitus acceptance. A comparison between the active treatments, including all assessment points, revealed significant differences in favour of ACT regarding tinnitus impact (Cohen's d=0.75) and problems with sleep. At 6 months, reliable improvement on the main outcome measure was found for 54.5% in the ACT condition and 20% in the TRT condition. The results suggest that ACT can reduce tinnitus distress and impact in a group of normal hearing tinnitus patients.

Place, publisher, year, edition, pages
Elsevier, 2011
Keyword
Acceptance and commitment therapy; Stress; Social workers; Burnout; Randomized controlled trial; Stress management
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-71844 (URN)10.1016/j.brat.2011.08.001 (DOI)000296941700003 ()21864830 (PubMedID)
Available from: 2011-11-07 Created: 2011-11-07 Last updated: 2017-12-08
4. A Randomized Controlled Trial of Internet-Delivered Cognitive Behavior Therapy and Acceptance and Commitment Therapy in the Treatment of Tinnitus
Open this publication in new window or tab >>A Randomized Controlled Trial of Internet-Delivered Cognitive Behavior Therapy and Acceptance and Commitment Therapy in the Treatment of Tinnitus
Show others...
2012 (English)In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 80, no 4, 649-661 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format. Method: Ninety-nine participants (mean age = 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n = 32), ACT (n = 35), or a control condition (monitored Internet discussion forum; n = 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up. Results: Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [-17.03, -2.94], d = 0.70, and 95% CI [-16.29, -2.53], d = 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [-44.65, -20.45], d = 1.34), with no significant difference between treatments (95% CI [-14.87, 11.21], d = 0.16). Conclusions: Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

Place, publisher, year, edition, pages
Washington, DC, USA: American Psychological Association (APA), 2012
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-76865 (URN)10.1037/a0027021 (DOI)000306861800011 ()22250855 (PubMedID)
Available from: 2012-04-20 Created: 2012-04-20 Last updated: 2017-12-07Bibliographically approved
5. Acceptance as a Mediator in Internet-delivered Acceptance and Commitment Therapy and Cognitive Behavior Therapy for Tinnitus
Open this publication in new window or tab >>Acceptance as a Mediator in Internet-delivered Acceptance and Commitment Therapy and Cognitive Behavior Therapy for Tinnitus
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Despite demonstrated efficacy of behavioral and cognitive techniques in treating the impact of tinnitus (constant ringing in the ears), little is known about the mechanisms by which these techniques achieve their effect. The present study examined acceptance of tinnitus as a potential mediator of treatment changes on global tinnitus severity in internet-delivered acceptance and commitment therapy (iACT) and internet-delivered cognitive behavior therapy (iCBT). Data from 67 participants who were distressed by tinnitus and who were randomly assigned to 1 of the 2 treatments were analyzed using a multilevel moderated mediation model. We predicted that acceptance as measured with the two subscales of the tinnitus acceptance questionnaire (i.e., activity engagement and tinnitus suppression) would mediate the outcome in iACT, but not in iCBT. Results provided partial support to the notion that mediation was moderated by treatment: tinnitus suppression mediated changes in tinnitus severity in iACT, but not in iCBT. However, inconsistent with the view that the treatments worked through different processes of change, activity engagement mediated treatment changes across both iACT and iCBT. Acceptance is identified as a key source of therapeutic change in behavioral-based treatments for tinnitus.

Keyword
Tinnitus, acceptance, mechanisms of change, internet-delivered selfhelp, cognitive behavior therapy
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-88336 (URN)
Available from: 2013-02-03 Created: 2013-02-03 Last updated: 2014-11-28Bibliographically approved
6. Costs of Suppressing Emotional Sound and Countereffects of a Mindfulness Induction: An Experimental Analog of Tinnitus Impact
Open this publication in new window or tab >>Costs of Suppressing Emotional Sound and Countereffects of a Mindfulness Induction: An Experimental Analog of Tinnitus Impact
2013 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 5, e64540- p.Article in journal (Other academic) Published
Abstract [en]

Tinnitus is the experience of sounds without an appropriate external auditory source. These auditory sensations are intertwined with emotional and attentional processing. Drawing on theories of mental control, we predicted that suppressing an affectively negative sound mimicking the psychoacoustic features of tinnitus would result in decreased persistence in a mentally challenging task (mental arithmetic) that required participants to ignore the same sound, but that receiving a mindfulness exercise would reduce this effect. Normal hearing participants (N = 119) were instructed to suppress an affectively negative sound under cognitive load or were given no such instructions. Next, participants received either a mindfulness induction or an attention control task. Finally, all participants worked with mental arithmetic while exposed to the same sound. The length of time participants could persist in the second task served as the dependent variable. As hypothesized, results indicated that an auditory suppression rationale reduced time of persistence relative to no such rationale, and that a mindfulness induction counteracted this detrimental effect. The study may offer new insights into the mechanisms involved in the development of tinnitus interference. Implications are also discussed in the broader context of attention control strategies and the effects of emotional sound on task performance. The ironic processes of mental control may have an analog in the experience of sounds.

Keyword
Mental control, tinnitus, emotional sound, mindfulness, suppression
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-88337 (URN)10.1371/journal.pone.0064540 (DOI)000318852400071 ()
Note

On the day of the defence date the status of this article was Manuscript.

Available from: 2013-02-03 Created: 2013-02-03 Last updated: 2017-12-06Bibliographically approved

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