Tinnitus Today • Summer 2022

TINNITUSTODAY To Promote Relief, Help Prevent, and Find Cures for Tinnitus

Vol. 47, No. 2, Summer 2022

Who’s Not Sleeping?

Constant Fatigue Is a Wake-Up Call to Seek Help Does Gender Influence Tinnitus and Sleep?

13 Tips for Building Quality Sleep Is There a Link Between Tinnitus and Sleep Apnea?

A publication of the

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Join the Jack Vernon Legacy Society Jack Vernon, PhD and leading tinnitus researcher, was a founding member of the American Tinnitus Association who dedicated his career to helping people with tinnitus. Jack’s goal was to provide meaningful relief from the condition while cultivating a research community that could advance treatments and eventually find cures.

Thanks to his leadership and vision, we have a far better understanding of tinnitus, its causes, and ways to reduce its negative impact on patients. Most importantly, today, we have an active community of researchers carrying on his mission to eliminate tinnitus.

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Table of Contents

Vol. 47, No. 2, Summer 2022

16 |

Cultivating Your Brain’s Superpower: 150 MINUTES/WEEK Reframing MODERATE TO VIGOROUS AEROBIC PHYSICAL ACTIVITIES Thoughts, Emotions, 32%–80% Behavior OF and INDIVIDUALS WITH TINNITUS REPORTSleep for Better SLEEP PROBLEMS Through Cognitive Behavioral Therapy REM

SPECIAL FEATURES

4| Wake-Up Call to Seek SLEEPING PILLS

Sleep Struggles Are a SLEEP INFOGRAPHIC Guidance and Make LOREM IPSUM Lifestyle Changes

RAPID EYE MOVEMENT

oes Tinnitus Anxiety 27|3–5 DServe a Purpose?

HOURS Life’s Ups 45|7–9 Nandavigating Downs With

PERSONAL STORIES

aming Unease 29| Tand Tinnitus With

Time, Practice, and Medication

the Days of 34 | Counting My New Normal

42| Bandryan,MeHyperacusis,

DREAMS PER NIGHT

SLEEP CYCLE ognitive Behavioral 7| CTherapy for Tinnitus-

1 DAY

Positive Psychology LIMIT OR AVOID

AWAKE

REM REM REM STAGE 1 RelatedREM Sleep Disorders

CAFFEINE, NICOTINE, AND ALCOHOL

STAGE 2 STAGE 3 STAGE 4 (DEEP SLEEP)

0

1

2

3

4

5

6

SCIENCE & RESEARCH NEWS HOUR

7

o We Experience 12 | DTinnitus While We Sleep?

ood Sleep Supports 26 | GSuccessful Tinnitus

ADULT AVERAGE SLEEP NEEDS

8

DREAM CATCHER

LOREM IPSUM & RESOURCES TINNITUS TOOLS

14 |

Tinnitus Q & A Addressing Minor Hearing Loss Can Make a Difference

to Tinnitus and Insomnia?

44 |

I s There a Link Between Tinnitus and Sleep Apnea?

Better Alternative to Sleeping Pills?

Tinnitus Resources for Building | | 48 21 Better Sleep Support Groups

potlight on 50 | SPatient Providers

Management

oes Gender Matter 32 | DWhen It Comes

Q &A 30 | TIsinnitus Melatonin a

3 Tips to Improve 23 | 1Quality Sleep urating Sounds for 25 | CBetter Sleep

ATA NEWS

ribute to 38| TUndaunted

Pioneers: David Baguley, PhD, and Bryan Pollard

 FROM THE BOARD CHAIR

Lulled to Sleep by White Noise and a Sense of Control

David Hadley, MBA Chair, Board of Directors

Why is it that most adults seem to give little thought to their own sleep until something undermines it, like jetlag, stress, fears, or tinnitus? And why is the fix for such nights often a pill—prescribed or over the counter—which sleep specialists view as problematic since pharmaceuticals don’t replicate naturalistic sleep or address the underlying issue of what is causing poor sleep? Yes, sleeping pills may be necessary, if not a godsend, in the short term, but no one wants to depend on pills to sleep. So, what do you do if your tinnitus keeps you up at night?

For years I relied on white noise from an air purifier to block out the “noise” of tinnitus. I viewed it as a small win.

Though it did not necessarily solve anything in the grander sense of my experiences with tinnitus, blocking out the ringing gave me a feeling of control. Over time, as I learned to habituate to my tinnitus and effectively ignore the sounds when I’m sleeping, I relied less on the white noise to sleep.

But if you’re anything like me, you still want to experience life in louder places, like restaurants and live events, and, without fail, if I don’t wear earplugs, I pay the price that evening when trying to sleep. Back to the air purifier I go, frustrated that the ringing is louder. I wake in the morning and try to assess: Is the ringing worse than I remember it? Stress levels rise, sleep gets worse for a day or two, and the air purifier becomes my friend again.

In this issue of Tinnitus Today, we look at the intermingling of tinnitus and disrupted sleep to provide insight into managing both better because poor sleep can contribute to louder tinnitus, and louder tinnitus can contribute to poor sleep—it’s a vicious cycle.

If you’re among the fortunate group of people with tinnitus who don’t struggle with sleep, I hope this issue provides you with greater understanding of the science of sleep, which continues to unveil evidence—that we intuitively know—that sleep is central to our short- and long-term mental and physical health.

MANAGING EDITOR Joy Onozuka American Tinnitus Association PUBLISHER Torryn P. Brazell, CAE, CFRE American Tinnitus Association PODCAST PRODUCER AND WRITER John A. Coverstone, AuD Sentient Healthcare, Inc. EDITOR-AT-LARGE James A. Henry, PhD National Center for Rehabilitative Auditory Research (NCRAR) U.S. Department of Veterans Affairs EDITORIAL ADVISORY PANEL Marc Fagelson, PhD East Tennessee State University Johnson City, TN USA Gail M. Whitelaw, PhD Department of Speech and Hearing Science The Ohio State University DIGITAL DESIGN & PRODUCTION TEAM JML Design, LLC ADVERTISING Tinnitus Today is the official publication of the American Tinnitus Association. It is published three times per year in April, August, and December and mailed to members and donors. The digital version is available online at www.ata.org. To grow your company’s brand reach, contact tinnitus@ata.org ATA HEADQUARTERS American Tinnitus Association 8300 Boone Blvd, Suite 500 Vienna, VA 22182 USA T: 800.634.8978 (Toll Free) www.ata.org TO GIVE TO THE ATA™ American Tinnitus Association c/o Truist Bank PO Box 424049 Washington, DC 20042-4049 The American Tinnitus Association is a nonprofit corporation, tax exempt under 501(c)(3) of the Internal Revenue Code, engaged in educational, charitable, and scientific activities.

Tinnitus Today magazine is © copyrighted by the American Tinnitus Association.

ATA™ is a registered trademark of the American Tinnitus Association.

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TINNITUS TODAY SUMMER 2022

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FROM THE PUBLISHER 

ATA BOARD OF DIRECTORS David Hadley, MBA, San Francisco–Chair Gordon Mountford, South Pasadena, CA– Vice Chair Ron Zagel, Grand Rapids, MI–Treasurer Robert Travis Scott, Abingdon, VA– Assistant Treasurer Stelios Dokianakis, AuD, CH−TM, Holland, MI–Secretary Jeff Bingham, San Diego, CA Shahrzad Cohen, AuD, CH−TM, Sherman Oaks, CA Sara Downs, AuD, Duluth, MN Phillip Gander, PhD, Iowa City, IA Fatima Husain, PhD, Champaign, IL Brian Lofman, PhD, Salinas, CA John Minnebo, MBA, Philadelphia, PA Julie Prutsman, AuD, Highlands Ranch, CO Dan Torpey, CPA, Irving, TX Robert M. Traynor, EdD, MBA, CH−TM, Fort Collins, CO Melissa Wikoff, AuD, CH−TM, Atlanta, GA Jinsheng Zhang, PhD, Detroit, MI Torryn P. Brazell, Vienna, VA–CEO HONORARY DIRECTOR William Shatner, Los Angeles, CA ATA SCIENTIFIC ADVISORY COMMITTEE Fatima T. Husain, PhD–Chair University of Illinois, Urbana-Champaign Champaign, IL USA Carey D. Balaban, PhD University of Pittsburgh, Pittsburgh, PA USA Christopher R. Cederroth, PhD Karolinska Institute, Geneva, Switzerland Marc Fagelson, PhD East Tennessee State University Johnson City, TN USA Avril Holt, PhD Wayne State University, Detroit, MI Jay Piccirillo, MD Washington University, St. Louis, MO Tricia Scaglione, AuD University of Miami, Plantation, FL USA Roland Schaette, PhD UCL Ear Institute, London, England Grant D. Searchfield, PhD University of Auckland, Auckland, New Zealand LaGuinn Sherlock, AuD, CH–TM Walter Reed National Medical Center Bethesda, MD Sarah Theodoroff, PhD VA Portland Health Care System Portland, OR

Sleepless Nights Aren’t Always About Tinnitus Like the flick of a switch, I slept beautifully until I didn’t.

Suddenly, I was awake three or four nights a week at 2 a.m., staring at the ceiling fan going round and round.

Yes, I could hear my tinnitus if I listened for it, but it wasn’t waking me up or keeping me awake; it was my mind racing with thoughts.

After a month of this, I talked to my physician about prescription sleep medication. She prescribed zolpidem, the generic version of Ambien. I took the pill feeling like it was a ticket to good sleep. The problem was that I woke up feeling groggy and unable to concentrate, which wasn’t much of an improvement over ploughing through the day fatigued. Frustrated, I saw my physician again, who suggested that I try a low dose of clonazepam—a benzodiazepine often prescribed for anxiety—which did the trick.

Many of us are reluctant to reach for medication when we can’t sleep or when we’re struggling with tinnitus. We know it won’t “fix” the problem, so why risk the possible side effects? Because sometimes medication, when properly prescribed at the lowest dose possible for shortterm use, can make life more manageable. In my case, stress was the midnight alarm that I had to tackle to get back to sleeping soundly without medication, which I was able to do after a few weeks.

If you’re having trouble sleeping, I urge you to talk to your physician to pinpoint whether there’s something else besides tinnitus that’s disrupting your sleep. We know that diabetes, digestive issues, depression, anxiety, stress, chronic pain, sleep apnea, medications, and other factors can play a role in poor sleep. And, like all things, identifying the problem makes it much easier to find solutions that work and limit the need for pharmaceuticals.

More research is needed to explore the relationship between tinnitus and sleep, and the best methods for promoting good sleep despite tinnitus. I hope this issue of Tinnitus Today gives you a blueprint for considering factors that can contribute to poor and improved sleep because our health—both mental and physical—depends on it.

Torryn P. Brazell, CAE, CFRE Publisher

The opinions expressed by contributors to Tinnitus Today are not necessarily those of the publisher or the American Tinnitus Association. This publication provides a variety of topics related to tinnitus for informational purposes only.

ATA’s publication of any advertisement in any kind of media does not, in any way or manner, constitute or imply ATA’s approval or endorsement of any advertised product or service. ATA does not favor or endorse any commercial product or service.

Richard Tyler, PhD University of Iowa, Iowa City, IA USA

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SLEEP INFOGRAPHIC SLEEPING PILLS

Sleep Struggles Are a Wake-Up Call to Seek Guidance and Make Lifestyle Changes

By Sylvie Hébert, PhD

How Well Do You Sleep?

Do you experience sleep difficulties because of your tinnitus? If so, you are not alone. Sleep difficulties are SLEEP INFOGRAPHIC the most frequent complaints among adults with tinnitus.

Depending SLEEPING PILLS on IPSUM the type LOREM of study conducted (e.g., population study vs. clinical sample), from 32 percent to 80 percent of individuals with tinnitus report sleep problems.1,2 This is not surprising since even the mildest tinnitus can be heard in quiet environments.

Therefore, difficulty falling asleep in a quiet bedroom is a very common challenge among tinnitus patients, as are disrupted sleep (awakening 150 and MINUTES/WEEK during midsleep earlyCYCLE morning) SLEEP MODERATE TO VIGOROUS and daily fatigue.

AEROBIC PHYSICAL ACTIVITIES AWAKE

In turn, poor sleep quality before the onset of tinnitus may increase the perceived severity of tinnitus at onset. In sum, poor sleep remains an important problem long after tinnitus onset and beyond the period of care by healthcare 150professionals.

MINUTES/WEEK MODERATE TO VIGOROUS

AEROBIC PHYSICAL ACTIVITIES What Is Healthy Sleep?

Healthy sleep is generally defined 32%–80% as sleep of duration, OFadequate INDIVIDUALS WITH quality, 4 TINNITUS REPORT timing, and regularity.

Adults ages SLEEP PROBLEMS 18 to 64 years should get seven to nine hours and those 65 years and REM older should getEYE seven to eight hours RAPID MOVEMENT of good quality sleep on a regular basis, with consistent bedtimes and 3–5 wake-up times.

DREAMS PER NIGHT

7–9 HOURS 1 DAY

ADULT AVERAGE SLEEP NEEDS

LIMIT There is a large OR bodyAVOID of scientific CAFFEINE, NICOTINE, STAGE 2 data on the fundamental OF INDIVIDUALS WITH AND ALCOHOL role of STAGE 3 TINNITUS REPORT healthy sleep on physical, cognitive, STAGE 4 SLEEP PROBLEMS and mental health. Chronic DREAM CATCHER (DEEP SLEEP) 0 1 2 3 4 5 6 7 8 LOREMtoo IPSUM insufficient—or much—sleep HOUR Of particular concern is that nearly REM is associated with a wide range of RAPID EYE MOVEMENT half of tinnitus patients report sleep adverse health outcomes: altered disturbances as a persistent problem mental health such as anxiety, 3–5 five years after their first visit to the depression, and cognitive impairments DREAMS PER NIGHT clinic.3 Moreover, more severe sleep regarding memory and learning; and complaints are correlated with greater 7–9 HOURS physical health, including metabolic tinnitus severity, especially ADULT AVERAGEat night. syndrome, diabetes/impaired glucose SLEEP NEEDS STAGE 1

REM

REM

32%–80%

REM REM

1 DAY

4

LIMIT OR AVOID TINNITUS TODAY SUMMER 2022 CAFFEINE, NICOTINE, AND ALCOHOL

LOREM IPSUM

SLEEP CYCLE

AWAKE hypertension, and metabolism, REM REM REM REM STAGEheart 1 diseases. coronary STAGE 2 in general have more Older adults fragile sleep, STAGE 3 and poorer sleep quality than younger STAGE 4 adults. Because tinnitus (DEEP SLEEP) prevalence increases 0 1 2with 3 age, 4 is5 it 6 HOUR reasonable to attribute sleep problems solely to age? The answer is no. In a study in which sleep complaints of older adults with tinnitus were compared with those of age-matched adults without tinnitus, those with tinnitus had more complaints than their age-matched controls.5 Therefore, individuals with tinnitus are at increased risk of developing deleterious health problems in the long term, over and beyond their age and tinnitus severity.

Improving sleep, therefore, should be a priority for tinnitus patients and their clinicians to prevent development of more serious health problems.

Unfortunately, sleep problems remain largely undocumented or mismanaged by hearing healthcare professionals.

Interventions for Tinnitus: Do They Improve Sleep?

Can the sleep problems of tinnitus patients be alleviated by tinnitus interventions? In other words, if we “treat” tinnitus, or more precisely

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RAPID EYE MOVEMENT

3–5

SPECIAL FEATURE

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DREAMS PER NIGHT

SLEEP CYCLE AWAKE

7–9 HOURS 1 DAY

ADULT AVERAGE SLEEP NEEDS

manage it, do we reduce both tinnitus make sure you have addressed REM REM REM REM STAGE 1 LIMIT OR AVOID severity and sleep complaints? basic sleep hygeine principles: CAFFEINE, NICOTINE, STAGE 2 Surprisingly, very little data are AND ALCOHOL • Create STAGE 3 a consistent available to answer this question. bedtime routine.

STAGE 4 Some of this advice pertains DREAM CATCHER We can think about daytime or (DEEP SLEEP) • Make0your 1 bedroom 2 3 4a haven 5 6 7 8 LOREM IPSUM to lifestyle factors that can be nighttime interventions. Regarding HOUR for sleep (e.g., sleep on a easily modified, such as caffeine daytime interventions, counseling comfortable mattress, maintain a consumption, drinking alcohol in the with and without sound therapy and cool and dark bedroom) evening, eating a light dinner, and so being fitted with hearing aids have • Establish a positive association on. If such adjustments don’t improve been reported to improve both tinnitus between your bed and sleep. sleep, there are more advanced severity and sleep complaints.6–8 • Avoid bright light exposure in the sleep hygiene instructions derived Regarding nighttime interventions, evening and throughout the night. from cognitive behavioral therapy bedside sound generators or in-ear • Watch your caffeine, nicotine, and for insomnia (CBT-I) that can be devices delivering noise seem to alcohol intake. utilized. Cognitive behavioral therapy improve tinnitus severity (although • Be mindful of what you eat is a recognized therapeutic option sleep parameters or complaints were before sleep. for insomnia as well as tinnitus.11,12 not assessed).9,10 • Exercise regularly. recommendations, noted in In a nutshell, there is someSLEEP lowINFOGRAPHIC 150These MINUTES/WEEK • Stay awake during the day the box,TO are aimed at reassociating MODERATE VIGOROUS level evidence that managing tinnitus • Make time to relax.

SLEEPING PILLS AEROBIC PHYSICAL ACTIVITIES the bed, bedroom, and bedtime or sleep in general might improve LOREM IPSUM stimuli with sleep rather than with sleep and/or tinnitus. However, exactly 32%–80% the frustration and anxiety associated which aspect of sleep (falling asleep, OF INDIVIDUALS WITH with sleeplessness.

REPORT staying asleep, or overall sleep quality) 5 CBT-I Sleeping Tips TINNITUS SLEEP PROBLEMS The recently published Canadian is improved, or by what mechanisms, 1 Go to bed only when 24-Hour Movement Guidelines for remains unknown. tired at night.

REM Adults offers useful information about 2 Use the bed and RAPID EYE MOVEMENT physical activity, sedentary behavior, Basic Advice About bedroom only for and sleep.13 For instance, in addition to Getting a Good sleep and sex (i.e., no 3–5getting good sleep, it is recommended DREAMS PER NIGHT reading, TV watching, Night’s Sleep adults perform at least 150 minutes or worrying in bed).

Sleep disruptions can happen for 7–9of HOURS moderate to vigorous aerobic 3 Get out of bed and go to many reasons other than tinnitus, ADULT AVERAGE SLEEP CYCLE physical activities per week, muscle another room if you’re SLEEP NEEDS so it is useful to remind ourselves AWAKE strengthening activities using major unable to fall asleep or of some basic advice about good REM REM REM REM STAGE 1 LIMIT OR AVOID muscle groups at least twice a week, return to sleep within sleep hygiene, especially as we get 2 CAFFEINE, NICOTINE, STAGE and several hours of light physical 20–30 minutes. Return AND ALCOHOL older and our sleep becomesSTAGE more 3 activities. In addition, adults 65 years to bed only when vulnerable to lifestyle and external STAGE 4 old and older are recommended to DREAM CATCHER you’re tired. Repeat factors. For instance, sleeping(DEEP on SLEEP) a 0 1 2 3 4 5 6 7 8 LOREM IPSUM activities that improve undertake as necessary during HOUR bad mattress in a warm bedroom balance (e.g., dance, tai chi, yoga, or the night. may explain why your sleep is not simple leg raising with a chair). This is 4 Arise at the same optimal. Likewise, having a heavy quite a program! time every morning, dinner shortly before going to bed will regardless of how much interfere with sleep. slept.

SLEEPyouINFOGRAPHIC So, before considering any 150 MINUTES/WEEK MODERATE TO VIGOROUS 5 Avoid daytime naps. pharmacological treatment or more 1 DAY

specialized sleep disorder diagnosis,

SLEEPING PILLS LOREM IPSUM

AEROBIC PHYSICAL ACTIVITIES

32%–80%

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OF INDIVIDUALS TINNITUS TODAY SUMMER 2022 WITH TINNITUS REPORT SLEEP PROBLEMS

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Valuable resources for patients who wish to know more about sleep can be found on websites such as those of the American Academy of Sleep Medicine (https://aasm.org/clinicalresources/patient-info/), the Canadian Sleep Network (https://www.cscnweb. ca/material-for-patients-and-the-public), and the Sleep On It Campaign (https:// sleeponitcanada.ca/).

Management of sleep complaints in tinnitus remains an unmet therapeutic challenge. Yet sleep problems are one important factor that will prompt individuals with tinnitus to seek help for their tinnitus in comparison to those who will not,14 and lack of sleep is among the factors clearly identified as aggravating among tinnitus patients.

Poor sleep can entail important consequences on both overall health and tinnitus severity. In turn, lack of sleep may increase tinnitus severity and in the long term give rise on its own to many additional serious health issues. This is the reason why tinnitus patients should be aware of how they can improve their sleep and improve

their quality of life. If these tips are not sufficient to help, then it would be useful to seek professional help.

Sylvie Hébert, PhD, is a full professor at the School of Speech Pathology and Audiology and program director of Audiology at the University of Montreal, Canada.

Her research © Sarah Scott laboratory is particularly well known in the area of tinnitus stress and sleep disturbances.

1 K. Izuhara, K. Wada, K. Nakamura, et al. (2013).

Association between tinnitus and sleep disorders in the general Japanese population. Annals of Otology, Rhinology & Laryngology, 122(11), 701–706.

2 R. S. Tyler & L. J. Baker. (1983). Difficulties experienced by tinnitus sufferers. Journal of Speech and Hearing Disorders, 48(2), 150–154.

3 G. Andersson, P. Vretblad, H. C. Larsen, & L. Lyttkens. (2001). Longitudinal follow-up of tinnitus complaints. Archives of Otolaryngology—Head & Neck Surgery, 127(2), 175–179.

4 J. P. Chaput & J. Carrier. (2021). First sleep health guidelines for Canadian adults: Implications for clinicians. Sleep Medicine, 79, 117–118.

5 S. Hébert & J. Carrier. (2007). Sleep complaints in elderly tinnitus patients: A controlled study. Ear and Hearing, 28(5), 649–655.

6 S. Wakabayashi, H. Saito, N. Oishi, S. Shinde, & K. Ogawa. (2018). Effects of tinnitus treatments

on sleep disorders in patients with tinnitus.

International Journal of Audiology, 57(2), 110–114.

7 Tinnitus Retraining Therapy Trial Research, R. W. Scherer, & C. Formby. (2019). Effect of Tinnitus Retraining Therapy vs standard of care on tinnitusrelated quality of life: A randomized clinical trial.

JAMA Otolaryngology—Head & Neck Surgery, 145(7), 597–608.

8 R. Zarenoe, M. Hällgren, G. Andersson, & T. Ledin.

(2017). Working memory, sleep, and hearing problems in patients with tinnitus and hearing loss fitted with hearing aids. Journal of the American Academy of Audiology, 28(2), 141–151.

9 L. Handscomb. (2006, December). Use of bedside sound generators by patients with tinnitus-related sleeping difficulty: Which sounds are preferred and why? Acta Otolaryngologica Supplementum, (556), 59–63.

10 S. M. Theodoroff, G. P. McMillan, T. L. Zaugg, M. Cheslock, C. Roberts, & J. A. Henry. (2017).

Randomized controlled trial of a novel device for tinnitus sound therapy during sleep. American Journal of Audiology, 26(4), 543–554.

11 C. M. Morin, A. Vallières, B. Guay, et al. (2009).

Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: A randomized controlled trial. JAMA, 301(19), 2005–2015.

12 H. Hesser, C. Weise, V. Z. Westin, & G. Andersson.

(2011). A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Clinical Psychology Review, 31(4), 545–553.

13 R. Ross, J.-P. Chaput, L. M. Giangregorio, et al.

(2020). Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and adults aged 65 years or older: An integration of physical activity, sedentary behaviour, and sleep. Applied Physiology, Nutrition, and Metabolism, 45(10 Suppl.

2), S57–S102.

14 B. Scott & P. Lindberg. (2000). Psychological profile and somatic complaints between helpseeking and non-help-seeking tinnitus subjects.

Psychosomatics, 41(4), 347–352.

SLEEP CYCLE FIRST CYCLE

NON-REM

WAKE REM STAGE 1 STAGE 2 STAGE 3 STAGE 4

SECOND THIRD CYCLE CYCLE

FOURTH CYCLE

FIFTH CYCLE

WAKE REM LIGHT SLEEP DEEP SLEEP

While sleeping, the brain cycles through four stages of sleep, divided into two phases: Non-REM sleep and REM sleep. REM stands for rapid eye movement. Non-REM sleep occurs first and has three stages, including deep sleep. Dreams occur during REM sleep. Depending on the stage, it takes 70 to 120 minutes to complete a full cycle, after which it begins again at stage 1.

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SPECIAL FEATURE

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Cognitive Behavioral Therapy for TinnitusRelated Sleep Disorders

By James A. Henry, PhD

It has long been reported that sleep disturbance is one of the primary effects of tinnitus.1–4 These early studies revealed that about one-half of all people who complain of tinnitus report disrupted sleep.5 A very recent study confirmed these findings, showing that 54 percent of over 3,000 tinnitus participants reported sleep impairment.6 This article focuses specifically on how cognitive behavioral therapy (CBT) can be used to manage tinnitusrelated sleep disorders. Researchers L. McKenna and H. C. Daniel wrote a chapter in the book Tinnitus Treatment: Clinical Protocols that addresses this topic in detail.7 Rather than reinvent the wheel, the following is a review of that book chapter. The headings are copied directly from the chapter. This review expresses the views of the www.ATA.org

chapter’s authors, not necessarily the opinions of the present author.

Before reviewing the book chapter, some comments are in order. First, the authors of the chapter refer to the “cognitive behavioral model” and not to CBT specifically. Second, the chapter was published in 2006, and more recent publications are available from the main author (L. McKenna), who wrote about tinnitus and insomnia as far back as 2000.8 His views have evolved, including a new “cognitive-behavioral model of tinnitus distress that is more in keeping with contemporary psychological theories of clinical problems (particularly that of insomnia)”9 and the development of mindfulness-based cognitive therapy (MBCT) that combines mindfulness-based stress reduction (MBSR) with CBT.10–12 Third, McKenna is coauthor of a 2019 publication that

describes results of using insomniaspecific CBT (CBT-I) with 22 patients who had both bothersome tinnitus and sleep disturbance.13 “Reliable improvements” were seen for insomnia (67 percent of patients), tinnitus distress (50 percent), and psychological distress (38 percent).

In the same year, he coauthored a publication describing a protocol to evaluate CBT-I with 102 patients in a planned/future randomized controlled trial (RCT).14 The RCT was completed and results will be published soon.

Finally, a separate group of authors reviewed four RCTs that had been conducted to evaluate CBT-based interventions for insomnia in adults with tinnitus.15 They concluded, “Here, for the first time, we demonstrate that CBT-based interventions can significantly improve sleep in adults with tinnitus.”

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The Cognitive Behavioral Model Applied to Tinnitus and Insomnia7 The cognitive behavioral model suggests that what people think about their tinnitus (the cognitive component), rather than the tinnitus itself, determines if and how they react to it. It also suggests that changes in certain behaviors (the behavioral component) can improve or worsen a tinnitus problem. With respect to sleep, this model suggests that negative thinking during the day can cause detrimental behavioral changes. The combined effect of the negative thoughts and detrimental behaviors creates a state of arousal that makes it difficult to sleep. Not getting enough sleep then worsens the situation, thereby creating the classic vicious cycle.

Group Therapy for Tinnitus-Related Insomnia The authors focus on the grouptherapy approach, which is adaptable for individual therapy that is needed by some patients. The information taught in each group session builds on the knowledge gained from the previous session(s). In the group setting, members have the advantage of “meeting and listening to others who are in a similar situation, which can normalize a person’s experiences and reduce anxiety” (p. 83). Group dynamics are not always positive; two therapists are therefore used to safeguard against any 8

TINNITUS TODAY SUMMER 2022

difficulties that may arise during the sessions.

Patient Selection Criteria and Definitions Sleep problems can include difficulty falling asleep at night, difficulty returning to sleep after waking during the night, and waking up too early in the morning. These difficulties are often described as “sleep being light, broken, or restless, and not being restorative or refreshing.

Complaints about associated daytime problems such as tiredness or sleepiness, mood disturbance, and poor performance are also common” (pp. 83–84).

Diagnosing a sleep problem is often a matter of clinical judgment. However, certain criteria can be used to make the diagnosis:

1 2 3 4

It takes at least 30 minutes to fall asleep or to get back to sleep after waking during the night; total time awake when trying to sleep is at least 45 minutes; total sleep is less than six hours per night; and any of these problems occurs at least three times a week.

These are not rigid guidelines, but they do emphasize the importance of the quality of sleep and not just the quantity of sleep.

Identifying eligible patients for the group sessions involves determining the cause of the sleep problem, which may or may not be tinnitus related. Insomnia can occur for many reasons, including psychological disorders, restless leg syndrome, gastroesophageal reflux, various pain conditions, breathing disorders,

some medications, alcohol, and illicit drug abuse.

If patients are taking medications appropriately for their sleep problem, they are advised to continue taking them unless told otherwise by their physician. Patients whose primary problem is alcohol abuse are not enrolled in the program.

Assessment Patients are assessed prior to, during, and following the group sessions. The assessment includes questionnaires that assess emotional state (anxiety and depression), tinnitus complaints, and sleep quality.

Questionnaires are administered one month prior to therapy, at the start and end of therapy, and four months following therapy. Sleep diaries, which are used nightly, reveal sleep habits, sleep quality, and sleep efficiency, and they identify specific concerns that should be addressed by the intervention. Sleep diary data are displayed on graphs to show progress and provide feedback to patients. Patients also provide a “sleep narrative” that describes their “sleep and sleep-related behavior for a typical 24-hour period.” The sleep narrative is intended to reveal behaviors that may be contributing to the sleep problem and therefore in need of intervention.

Group Structure Each group consists of eight to 10 members. Meetings are held every other week and last two hours each. A total of eight meetings are held in addition to a four-month follow-up meeting.

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Treatment Protocol Tinnitus and Sleep Education The program starts with education to “demystify” concerns about tinnitus, sleep, and insomnia. Information about tinnitus focuses on the “habituation model” of tinnitus that was described by Hallam and colleagues in 1984.16 That model emphasizes how tinnitus tends to become less of a problem over time and that the majority of people are not significantly bothered by it. High anxiety and negative beliefs about tinnitus are generally factors that impede habituation.

Counseling information about sleep and insomnia is derived from psychological publications about sleep and, in particular, from the cognitive behavioral model of insomnia.17 Normal sleep time is addressed, and it is explained that the amount of sleep remains approximately the same from middle age to later life. Sleep stages are described with respect to rapid eye movement (REM) sleep and the four stages of non-REM sleep.

Cycling through the sleep stages can last 70 to 120 minutes, which is typically repeated four to five times a night in young adults. With older people, sleep is generally not as deep (very deep sleep may not occur), awakenings occur more frequently, and sleep is often described as “light and fragmented.”

Evidence from the scientific literature is presented to clarify common beliefs about the effects of insomnia. Patients with insomnia commonly complain of daytime sleepiness, concentration difficulties,

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impaired memory, and reduced ability to perform tasks. The literature suggests these effects may result from anxiety rather than the sleep loss per se.

It is explained to patients that because sleep problems are experienced by only about half of patients with tinnitus, clearly tinnitus does not inevitably lead to insomnia.

The factors causing insomnia are very likely to be psychological in nature and therefore amenable to psychological treatment. It is the authors’ view that “tinnitus does not wake people up.”

Upon awakening in the middle of the night, the tinnitus may be the first thing that comes to mind. Remaining awake, however, would be due to psychological factors.

Individual Goal Setting Unlike many formal research programs, sleep goals are not standardized across patients. Because of the highly subjective nature of insomnia, and the many variables that can be involved, the approach is to address each individual concern.

Goals must be realistic with respect to what is known about normal sleep and what can be accomplished in the time available within the clinic setting.

Relaxation Patients are taught muscle relaxation exercises.

They receive recorded relaxation instructions and are asked to practice relaxation every day.

They learn how relaxation exercises reduce muscle tension and arousal of the autonomic nervous

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system. These changes in turn reduce heart rate, respiration, blood pressure, and even intrusive thoughts. All these effects can be effective in promoting sleep. It is important that patients appreciate the rationale for relaxation therapy and that they distinguish it from activities thought to be relaxing, such as watching television or reading a book.

Cognitive Therapy Cognitive therapy is also referred to as “cognitive restructuring,” and the initial counseling explains the relationships among thoughts, behavior, emotions, and bodily sensations. Illustrations are given to show how thoughts and emotions are related. For example, if a friend does not show up for dinner, the reaction might be anger, which turns to feelings of sympathy and concern when learning the friend was in an accident.

Once this relationship is understood, it is explained how negative thoughts about tinnitus and sleep problems contribute to the “vicious cycle” of anxiety, heightened awareness of tinnitus, and poor sleep. Patients are asked to think about how their own thoughts may contribute to these effects. They are also asked to create a diary as “homework” to monitor their thoughts and emotions. The diary information is used by the therapist to assist in promoting alternative and more helpful thoughts regarding patients’ tinnitus and sleep problems.

Video Modeling The authors cite evidence for the therapeutic effect of others coping with a similar psychological problem.

In the group sessions, patients are shown interviews of prior patients who had tinnitus-related sleep problems who are now coping TINNITUS TODAY SUMMER 2022

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well after receiving the intervention. This provides a successful model that patients can emulate.

Sleep Hygiene What people believe influences what they do. If they have a problem sleeping, they do things they believe will help them sleep.

These things might include alcohol, medications, and watching television in bed. Whereas such strategies might provide short-term benefit, they may just perpetuate the vicious cycle produced by poor sleep habits.

This is explained to patients who begin to question these kinds of behaviors. They are then taught about “sleep hygiene and the behavioral changes they can begin to make to promote sleep.”

• Alcohol may help to initiate sleep, but it can disrupt sleep, especially during the second half of the night.

• Coffee and anything containing caffeine should be avoided in the evenings.

• Nicotine has a stimulating effect and should be reduced or avoided prior to bedtime.

• Food intake should be regulated so as to not be too full or too hungry at bedtime. It is also advised to not eat in the middle of the night.

• Exercise causes arousal and therefore should not be done close to bedtime.

• Sound should be present in the bedroom 24/7 to become an inherent part of the bedroom environment. The sound should not be stimulating to avoid it causing arousal.

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•

•

•

•

Watching television or reading a book should take place in a different room.

Clock-watching can invoke anxiety or dread and interfere with sleep.

Clocks should not be visible in the bedroom and should be turned around if an alarm is needed.

Time in bed should not be increased in the attempt to “catch up” on lost sleep. It is important not to associate being in bed with being awake. If awake for 20 minutes in the middle of the night, the person should get up and not go back to bed until sleepy. Sleeping should be avoided during the day and a regular sleep-wake schedule is encouraged.

Worry tends to be at the “forefront of our thoughts” at nighttime. Worry creates a state of arousal that makes it difficult to sleep. A suggestion is to write down, prior to bedtime, any anxious thoughts along with possible solutions. Then, when awake in the night, remember that everything possible has been done to deal with the worries and that they will be attended to tomorrow.

The evening routine should promote slowing down, relaxing, and sleeping. This would include incorporating all the sleep hygiene behaviors.

Other Methods of Controlling Thoughts It is believed that “unwanted and intrusive thoughts” are a primary cause of difficulty falling asleep.

People often try on their own to control such thoughts in ways that are ultimately unhelpful. Even the “cognitive restructuring” exercises that are taught with CBT can make the thoughts more prominent and therefore anxiety-provoking. To focus attention away from these thoughts, it is suggested to use “imagery distraction techniques” or “articulatory suppression.”

• Imagery distraction techniques are the use of mental images of “interesting and engaging” situations that are also “pleasant and relaxing.” Patients are asked in a group session to describe such a situation in detail to reinforce the image. Any image leading to arousal should be avoided.

• Articulatory suppression involves the repetition of a neutral word, such as “the.” The repetition should be subvocal (meaning, to imagine the word and how it is spoken) and at a rate that suppresses other thoughts.

Performing this exercise can be helpful to pay less attention to the tinnitus. It can be counterproductive, however, and it is therefore suggested to combine the technique with a pre-bedtime routine of “cognitive restructuring or problem-solving exercises.”

Conclusion The book chapter “Tinnitus-Related Insomnia Treatment” in Tinnitus Treatment: Clinical Protocols describes the approach its authors use to clinically manage tinnitus-related insomnia. The approach is based as www.ATA.org

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much on the scientific literature pertaining to insomnia as it is on the tinnitus literature. The key assumption is that tinnitus itself does not cause difficulty sleeping.

Rather, the cause is the anxiety that is associated with the tinnitus. As of this writing, the vast majority of patients who attend this group-therapy program report some benefit.

James A. Henry, PhD, is a certified and licensed audiologist with a doctorate in behavioral neuroscience. He is employed as a Veterans Affairs (VA) Rehabilitation, Research & Development (RR&D) Senior Research Career Scientist at the VA RR&D National Center for Rehabilitative Auditory Research (NCRAR) located at the VA Portland Health Care System. He is also Research Professor in the Department of Otolaryngology—Head and Neck Surgery at Oregon Health & Science

University. For the past 25 years, he has devoted his career to tinnitus research.

His overall goals are to develop and validate clinical methodology for effectively helping individuals with bothersome tinnitus and to increase accessibility to evidence-based tinnitus care.

1 S. Erlandsson. (2000). Psychological profiles of tinnitus patients. In R. S. Tyler (Ed.), Tinnitus handbook (pp. 25–57). Singular.

2 S. C. Jakes, R. S. Hallam, C. Chambers, & R. Hinchcliffe. (1985). A factor analytical study of tinnitus complaint behaviour. Audiology, 24, 195–206.

3 M. Meikle & E. Taylor-Walsh. (1984). Characteristics of tinnitus and related observations in over 1800 tinnitus patients. In: Proceedings of the Second International Tinnitus Seminar, New York 1983 (pp.

17–21). Journal of Laryngology and Otology (Suppl.

9). Invicta Press.

4 R. S. Tyler & L. I. Baker. (1983). Difficulties experienced by tinnitus sufferers. Journal of Speech and Hearing Disorders, 48, 150–154.

5 J. A. Henry, K. Dennis, & M. A. Schechter. (2005).

General review of tinnitus: Prevalence, mechanisms, effects, and management. Journal of Speech, Language, and Hearing Research, 48(5), 1204–1234.

6 H. Gu, W. Kong, H. Yin, & Y. Zheng. (2022).

Prevalence of sleep impairment in patients with tinnitus: A systematic review and single-arm metaanalysis. European Archives of Otorhinolaryngology, 279(5), 2211–2221.

7 L. McKenna & H. C. Daniel. (2006). Tinnitus-related insomnia treatment. In R. S. Tyler (Ed.), Tinnitus treatment: Clinical protocols (pp. 81–95). Thieme.

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8 L. McKenna. (2000). Tinnitus and insomnia. In R. S. Tyler (Ed.), Tinnitus handbook (pp. 59–82). Singular.

9 L. McKenna, L. Handscomb, D. J. Hoare, & D. A. Hall. (2014). A scientific cognitive-behavioral model of tinnitus: Novel conceptualizations of tinnitus distress. Frontiers in Neurology, 5, 196.

10 E. Marks, P. Smith, & L. McKenna. (2020). I wasn’t at war with the noise: How mindfulness based cognitive therapy changes patients’ experiences of tinnitus. Frontiers in Psychology, 11, 483.

11 L. McKenna, E. M. Marks, C. A. Hallsworth, & R. Schaette. (2017). Mindfulness-based cognitive therapy as a treatment for chronic tinnitus: A randomized controlled trial. Psychotherapy and Psychosomatics, 86(6), 351–361.

12 L. McKenna, E. M. Marks, & F. Vogt. (2018).

Mindfulness-based cognitive therapy for chronic tinnitus: Evaluation of benefits in a large sample of patients attending a tinnitus clinic. Ear and Hearing, 39(2), 359–366.

13 E. Marks, L. McKenna, & F. Vogt. (2019). Cognitive behavioural therapy for tinnitus-related insomnia: Evaluating a new treatment approach. International Journal of Audiology, 58(5), 311–316.

14 E. Marks, C. Hallsworth, & L. McKenna. (2019).

Cognitive behavioural therapy for insomnia (CBTi) as a treatment for tinnitus-related insomnia: Protocol for a randomised controlled trial. Trials, 20(1), 667.

15 F. Curtis, D. Laparidou, C. Bridle, et al. (2021).

Effects of cognitive behavioural therapy on insomnia in adults with tinnitus: Systematic review and meta-analysis of randomised controlled trials. Sleep Medicine Reviews, 56, 101405.

16 R. Hallam, S. Rachman, & R. Hinchcliffe. (1984).

Psychological aspects of tinnitus. In S. Rachman (Ed.), Contributions to medical psychology (Vol 3, pp.

31–53). Pergamon.

17 A. G. Harvey. (2002). A cognitive model of insomnia.

Behaviour Research and Therapy, 40(8), 869–893.

Medical Disclaimer The content in Tinnitus Today magazine is intended to provide helpful health information for the general public. It is made available with the understanding that the American Tinnitus Association (ATA) is not engaged in rendering medical, health, psychological, or any other kind of personal professional services.

The magazine content should not be considered complete and, therefore, does not cover all physical conditions or their treatment as it relates to tinnitus and tinnitus management.

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The ATA always recommends that you consult and work with a medical, health, or other competent professional when considering the best course of tinnitus management.

This begins with a medical examination to rule out possible underlying medical causes for tinnitus. If you’re interested in adopting guidance/suggestions made in the magazine, you should discuss this first with your medical provider before doing so.

Any information about drugs and supplements contained in the magazine is general in nature, and does not

cover all possible uses, actions, precautions, side effects, or interactions of the medicines mentioned. The content of the magazine is not intended as medical advice for individual problems or for making an evaluation for pursuing a particular course of action.

The ATA and authors of articles in the magazine specifically disclaim all responsibility for any liability, loss, or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the content in the magazine.

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 SCIENCE & RESEARCH NEWS

Do We Experience Tinnitus While We Sleep?

Summary by John A. Coverstone, AuD

It’s well known that tinnitus can cause problems in getting to sleep because of the disruption from the unwanted sound. What about the relationship of tinnitus and sleep in the brain? Do we experience tinnitus while we sleep? Does tinnitus affect the brain functions involved in sleep?

To answer these questions, researchers from Oxford University did a comprehensive literature review of research relevant to brain functions during sleep, tinnitus, or both. The goal of this review was to bring together various literature on the subject. The review was led by doctoral student in neuroscience Linus Milinski and was published in Brain Communications in April 2022.1 Previous research has linked tinnitus with increased spontaneous activity in the auditory pathways, as well as greater excitability of auditory nerves.

This means that sounds traveling through the auditory system result in auditory nerves responding more strongly than in people without tinnitus.

This occurs with hearing loss as well. It is often called auditory gain, or central gain, and can turn up the volume of sound dampened by cochlear hearing loss such that people don’t realize they have a hearing problem.

These changes may be limited to the auditory system but often are 12

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found across a wide array of brain regions when tinnitus has been present for a long time. Some regions where altered brain activity has been found are also implicated in changing brain activity between sleep and wakefulness. In reviewing the available literature, Milinski and his colleagues theorized that abnormal brain activity from tinnitus may cause a state of hyperarousal similar to insomnia and prevent natural onset of restorative sleep. Restorative sleep is essential for us to feel rested and refreshed and for our brain to do the daily housekeeping that is necessary for normal functioning.

Milinski and his colleagues wondered whether these processes may play a role in the persistence of tinnitus after the initial event that causes onset of the sound. For instance, we know that restorative sleep is necessary for our brains to sort through events of the day and selectively commit those to long-term memory, a process called consolidation. Is it possible that restorative sleep has an effect on newly emerged tinnitus that is similar to consolidation?

Although the idea is not proven in research at this time, the ideas Milinski and his colleagues found in the literature led to a theory that the increased excitability of brain pathways associated with tinnitus may cause a

state of hyperarousal. They believe it may be like parasomnia, a condition where the frontal—or conscious— areas of the brain are in a sleep state, but the limbic areas—those involved in emotional responses and behaviors associated with survival—and motor areas of the brain are in a wakeful state. A 2020 study published in the Journal of the Formosan Medical Association2 showed that people with tinnitus had a higher incidence of parasomnia, night terrors, and sleep walking than the general population.

When we are sleeping, we are generally disconnected from our surrounding environment—particularly, from our sensory signals. However, the brain is known to be highly receptive to sound during sleep. Prior studies have shown that auditory evoked potentials (an electroencephalogram response to sound stimuli) are preserved during sleep. Rhythmic stimulation can help with consolidation of memories during sleep. At the same time, white noise has been shown to interfere with sleep in some people, causing lighter sleep and more frequent arousal. Milinski theorized that tinnitus may affect sleep by causing localized arousal during sleep and by providing an auditory trigger that arouses people from sleep. It should be noted, however, that tinnitus is only occasionally similar to white noise and tinnitus is internally generated. As a result, it www.ATA.org

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may not translate to causing the same disruption of sleep as was shown in the studies Milinski references.

Indeed, various studies have shown people with tinnitus tend to have lighter sleep, more frequently rouse from sleep, and have a higher incidence of insomnia. No research currently supports a direct link between tinnitus and altered brain activity or changes in sleep patterns.

Research shows that these things are commonly present at the same time, but that does not provide a “cause

and effect” relationship where we can say that one causes the other.

However, Milinski believes there is enough research showing associations between these conditions that a direct relationship should be considered and researched further.

Some research has shown improvement in memory formation when rhythmic sounds are played, as mentioned earlier. It may be possible to present some form of auditory stimulus that mitigates tinnitus while a subject is sleeping. This is called

guided plasticity and is currently being researched for a wide range of conditions. If successful for tinnitus, people may be able to play specific sounds during sleep to encourage brain consolidation of tinnitus, leading to less annoyance and quieter tinnitus while awake.

1 L. Milinski, F. Nodal, V. Vyazovskiy, & V. Bajo.

(2022). Tinnitus: At a crossroad between phantom perception and sleep. Brain Communications, 4, 3. https://doi.org/10.1093/braincomms/fcac089 2 SR. Hwang, SW. Hwang, Y. Chu, J. Hwang (2020).

Association of sleep terror, walking or talking and tinnitus. J Formos Med Assoc. Published online April 11, 2020. Doi:10.1016/j.jfma.2020.03.014

What’s Insomnia?

According to the American Academy of Sleep Medicine, nearly three in 10 people in the U.S. report that insomnia negatively impacts their lives. It is more common among women than men, and can be caused by nightshift work, long-term illnesses, and mental health conditions such as depression and anxiety, among other things. But what exactly is insomnia as opposed to the occasional sleepless night?

Like all medical disorders, specific symptoms and criteria guide diagnosis and treatment of insomnia.

Chronic Insomnia Chronic insomnia refers to • difficulty falling asleep/staying asleep, or regularly waking up earlier than desired; • daytime fatigue, depression, low energy, and concentration and memory issues; and • sleep difficulties occurring at least three times a week for at least three months.

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Acute Insomnia Acute insomnia • lasts for one night or more, and includes the symptoms listed under chronic insomnia.

Types of Insomnia • Primary insomnia means your sleep problem isn’t related to a health condition but rather is related to factors around sleep: stress, your sleep environment (noisy, temperature, light), or sleep schedule (jet lag, shift work, poor sleep hygiene).

• Secondary insomnia means your sleep issues are connected to health conditions, such as dementia, hormone imbalances, sleep apnea, pain, arthritis, depression, substance abuse, or cancer, and the medications used to treat them.

Diagnosis • Physical exam • Use of sleep diary to track sleep patterns

• Sleep test (in home or at a sleep center) • Referral to a sleep specialist

Treatment • Acute insomnia may not require treatment if it’s primary insomnia and the related issues are resolved.

• For chronic insomnia, the recommended first line of intervention is cognitive behavioral therapy for insomnia (CBT-I).

• Although pharmaceuticals may be prescribed for someone struggling with sleep, they are considered a short-term intervention and come with side effects.

• Over-the-counter medications for sleep should be avoided, according to the Centers for Disease Control and Prevention, because they can impair daytime activities and are less effective over time. Hence, it’s better to discuss your sleep concerns with your physician than to self-medicate.

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 TINNITUS RESOURCES

Tinnitus Q & A Addressing Minor Hearing Loss Can Make a Difference

Answered by Gail M. Whitelaw, PhD and Olivia Wagoner, BS, Doctor of Audiology candidate

Question: I recently developed tinnitus and was told to see an audiologist by my ENT physician.

The audiologist I saw found minor hearing loss at high frequencies and suggested that I consider getting maskers, not hearing aids, which are expensive. Is that all that’s available for people with tinnitus who don’t have much hearing loss? Is mild hearing loss really something I can ignore, or will it make my tinnitus worse?

Thank you for this insightful set of questions. Some models of tinnitus suggest that when hearing loss occurs, the brain looks for the “missing sound,” and when it does not find it, it creates its own sound, tinnitus. Addressing the hearing loss can often help to address the tinnitus.

Because hearing loss and tinnitus often coexist, research suggests that 60–70 percent of people with tinnitus note a significant decrease in tinnitus perception when using hearing aids that have been fitted well. The degree of hearing loss is less of a factor than providing appropriate amplification for your hearing loss. Many current hearing aids include tinnitus programs that provide the benefits of both improved hearing and the ability to manage tinnitus. Tinnitus programs built into 14

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hearing aids can provide significant benefits in the habituation of tinnitus and support other types of treatment options and can be used as “maskers.”

Talking with your audiologist and setting up a hearing aid demonstration, including several weeks of usage (not just in the office for a short trial), will help you determine potential benefits and will be a good investment of your time.

The audiologist should spend time understanding your needs, support you in using the hearing aids, and verify the fitting with “real ear” or probe microphone measures to ensure that the hearing aids are appropriately fitted. In addition to hearing aids, there are many other types of management options.

If you choose to try a masker instead, a number of options are available and may help in habituation with your tinnitus. A trial with maskers can let you experience the potential benefits you may obtain as part of your tinnitus treatment. Maskers may be flexible in terms of addressing the tinnitus, although they may provide fewer options than what may be available in a hearing aid or one of the many available tinnitus apps. Maskers may be less expensive than a hearing aid solution.

Hearables, which are neither hearing aids nor maskers, may provide some benefit to you from a hearing perspective. Hearables are categorized as personal sound-amplification

products (PSAPs), which are designed to increase the volume of sound in specific environments, such as when listening for the call of a bird or the voice of a lecturer. Currently, hearables are not approved by the U.S. Food and Drug Administration (FDA) and are considered a consumer electronic product. Hearables may look similar to a hearing aid or Bluetooth headphones.

Although there is not much research on the use of hearables as a tool in tinnitus treatment, it is a topic of interest and shows promise for incorporating artificial intelligence (AI) and therapy options that may personalize tinnitus treatments. Searchfield and colleagues described the role of hearables currently and into the future.1 If you have questions about hearable technologies, you are encouraged to talk with your audiologist in addition to investigating options available to consumers.

You should work with an audiologist who has experience working with tinnitus patients, and together you should create a management plan, which may include hearing aids and/ or maskers, but should also include a broader approach to management.

Other types of technology options, such as Neuromonics or Levo, may be appropriate options for you and are often used by people with normal hearing or mild hearing loss. You might also pursue Tinnitus Retraining Therapy (TRT), a therapy technique that assists www.ATA.org

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in habituating to the tinnitus and minimizing the impact of emotional responses. Tinnitus treatment should also incorporate a team approach, so in addition to working with your audiologist, you may work with a psychologist who provides cognitive behavioral therapy (CBT).

When considering audiologists, seek someone specialized in tinnitus management. Some audiologists have certification from the Tinnitus Practitioners Association (https:// tinnituspractitioners.org/resources/), while others are Certificate Holders in Tinnitus Management (CH–TM) from the American Board of Audiology (https://eaudiology.audiology.org/ tinnitus). The American Tinnitus Association has a database of audiologists in your area that may help you identify an audiologist who can best meet your needs (https://www. ata.org/providerlist).

You should feel that the audiologist is listening to your questions and concerns and that you have shared decision-making with your provider.

Asking questions about why a recommendation was made and the evidence or research supporting the recommendation will provide insight to support a management plan. In your case, you may want to ask about why hearing aids were not recommended, what you may expect from the use of hearing aids, and what other options may be available either in addition to or in place of hearing aids. Express your preferences, ideas, and concerns so that the audiologist understands your perspective. Ask questions that keep lines of communication open and provide feedback on the management program as you work through it. www.ATA.org

Sometimes it can be helpful to speak with a former tinnitus patient. However, because of HIPAA regulations, your audiologist may not be able to introduce you to another patient. Nonetheless, there may be patients in the practice who are willing to talk with you about their tinnitus management and their experience with your audiologist. Also, ask your audiologist if they have available resources on tinnitus support groups in your area. If there are none, speak with your audiologist about setting up a clinic-specific support group, where other people with tinnitus and their family can meet. Online open-access support groups can be found on the ATA’s website at https://www.ata. org/managing-your-tinnitus/supportnetwork/support-group-listing.

Treating hearing loss, regardless of the degree, can provide benefit in tinnitus management. Once you start wearing hearing aids, you may be surprised that your hearing loss impacts both your communication and your quality of life and is really more of an issue than you anticipated, which reflects findings that hearing loss is commonly underestimated as a problem compared with the presence of tinnitus.2 Research also shows that most people wait 7–10 years to address hearing loss, so you should be commended for considering ways to improve your hearing and hopefully reduce your tinnitus perception at the same time. “Ignoring” your hearing loss is not likely to make your tinnitus perception worse, but addressing your hearing loss at this time will show you the potential benefits in both hearing and listening as well as the potential for tinnitus management. The presence of tinnitus can also interfere with your

ability to attend to auditory information that you want to hear; therefore, hearing aids may provide a benefit beyond amplifying sound to address your hearing loss. As noted previously, trial usage of hearing aids can provide insight into the individual benefit you will receive, and most audiologists offer a 30-day trial period to help with the adjustment to hearing aids and to see their potential benefits.

Gail M. Whitelaw, PhD, is a clinical associate professor and the Director of the Speech-LanguageHearing Clinic at The Ohio State University in Columbus, OH. Dr. Whitelaw is a clinical preceptor in the Doctor of Audiology (AuD) program and also provides direct clinical care. Her clinical interests are in tinnitus and related sound tolerance disorders, auditory processing disorders, traumatic brain injury, and professional leadership development.

She is a Certificate Holder in Tinnitus Management (CH–TM) from the American Board of Audiology. Dr. Whitelaw is a frequently invited presenter on the topic of tinnitus management, particularly as it relates to children and teens.

Olivia Wagoner is a first-year Doctor of Audiology student attending Central Michigan University. In 2021, she received her Bachelor of Science in Communication Sciences and Disorders from Baldwin Wallace University, Berea, Ohio. Her clinical interests include tinnitus management, auditory processing disorders, and misophonia.

1 G. D. Searchfield, P. J. Sanders, Z. Doborjeh, et al.

(2021). A state-of-art review of digital technologies for the next generation of tinnitus therapeutics.

Frontiers in Digital Health, 3, 724370.

2 J. Henry. (2020). Distinguishing between hearing loss, tinnitus, and hyperacusis: A recommended tinnitus-evaluation protocol for audiologists. Tinnitus Today, Spring, 22–26.

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Cultivating Your Brain’s Superpower Reframing Thoughts, Emotions, and Behavior for Better Sleep Through Cognitive Behavioral Therapy

By Joy Onozuka

Throughout the day, our brain processes an endless stream of information pouring in from the environment—visual cues, smells, tastes, sounds, movement. While we sleep, our brain continues to monitor the surrounding environment, assessing for new stimuli, which explains why we often sleep poorly the first evening in an unfamiliar place—something new could be something threatening.

This conscious and mostly unconscious processing of environmental stimuli allows us to conserve energy, focus on our daily lives, and stay safe. However, sometimes the brain misconstrues events or latches on to negative associations that trigger the limbic system to flood the body with a fightor-flight (stress) response, marked by increased heartbeat, elevated 16

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blood pressure, heightened anxiety, or aggression. Internally, thoughts alone—like imagining what’s in that letter from the IRS—can cause a cascade of stress hormones that leaves us feeling on edge when nothing has changed in the external environment.

This nagging, persistent feeling that something’s not right is termed hyperarousal. Hyperarousal impedes our ability to relax and cope effectively with challenges that arise, such as tinnitus and sleep issues. And because hyperarousal often accompanies intrusive tinnitus, it’s easy to feel trapped in a vicious cycle of elevated tinnitus and poor sleep and a neverending feeling of being on alert.

So, how can we break that cycle? The strongest evidence supports cognitive behavioral therapy (CBT).

Interestingly, cognitive behavioral therapy, which focuses on changing distorted perceptions and behaviors, is the most efficacious intervention for both poor sleep and tinnitus and can help diminish anxiety and hyperarousal. The brain is quick to make associations, so untangling negative emotions associated with tinnitus and poor sleep and priming the brain for positive or neutral reactions to these challenges instead are goals for both habituation to tinnitus and improved sleep.

And there is a specific branch of CBT dedicated to improving sleep: cognitive behavioral therapy for insomnia. If you’ve never heard of CBT-I, you aren’t alone. It wasn’t until 2016 that the American College of Physicians (ACP) made a landmark endorsement of cognitive behavioral therapy for insomnia as the first line of treatment for adults with chronic www.ATA.org

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insomnia, including older adults, who are more prone to poor sleep.

CBT-I has been shown to be effective for people with posttraumatic stress disorder, those who are recovering from cancer treatment, and those who don’t meet the criteria for chronic insomnia—which is to say it can be helpful for anyone who experiences periodic sleep problems, including those with tinnitus.

What’s noteworthy is CBT-I shows the best long-term effects, helping 70 to 80 percent of people who utilize it, whereas pharmaceuticals prescribed for poor sleep, which are intended for short-term use, come with a long list of potential negative side effects, including dependency and daytime drowsiness, and they don’t address the underlying problems of sleeplessness, whereas CBT-I can.

As someone who has long struggled with sleep, I was excited to join a clinical trial for a CBT-I app in 2019. Like CBT for tinnitus, CBT-I focuses on exploring the negative thoughts, feelings, and behaviors that perpetuate the problem of poor sleep. Whereas a typical in-person CBT-I program consists of six to eight sessions with a trained physician, counselor, therapist, or psychiatrist (see reference box for resources), an app can be either fully automated or used in conjunction with a provider via telehealth or email. In my case, the CBT-I app was fully automated.

Through the app, I learned a range of techniques and behaviors to improve my sleep, including sleep restriction, sleep hygiene, relaxation training, stimulus control, and mindful awareness of the connections

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between thoughts, behaviors, and sleep.

In CBT-I, the process of cognitive restructuring is used to correct dysfunctional thoughts that disrupt sleep. For instance, prior to CBT-I, I would always check my bedside clock when I had trouble falling asleep or going back to sleep after waking up at night. I’d routinely calculate the remaining time I could sleep. The longer I remained awake, the more alert and active my brain became as I imagined how awful the next day would be pushing through brain fog and fatigue. These negative thoughts, while seemingly true in my mind, were only a prediction of a negative outcome and me believing that that outcome would in fact occur. This is called catastrophizing. Sleep restriction, another facet of CBT-I, challenged this engrained thought process of catastrophizing—and every fiber of my being the first week or so.

So, what is sleep restriction?

First, it’s not for everyone. It’s not recommended for people with medical conditions that can be made worse by lack of sleep, such as seizures and bipolar disorder. Second, the purpose is to limit your time in bed to only when you’re sleeping—meaning, if you’re in bed, you’re asleep—so you must adhere to a consistent sleep schedule. To figure out my sleep schedule, in a sleep diary I recorded the amount of time I slept versus the amount of time I spent in bed.

On average, I was in bed for seven or eight hours but asleep for only six.

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From my chosen wake-up time of 6 a.m., I counted backward six hours to determine my sleep-restricted bedtime, which was midnight. I would not get into bed until midnight each night, the idea being that, by increasing the drive to sleep with a late bedtime, it would be easier to fall asleep and stay asleep.

In the app, video modules highlighted that people usually can function well despite fatigue, so my negative thoughts about poor sleep ruining the next day were cognitive distortions, not reality. But, despite the app’s educational components, I remained convinced that my thoughts on this issue were right. However, ten days of restricted sleep, though uncomfortable, affirmed that I could indeed function well the next day, dispelling that thought.

I also followed these daytime steps to promote better sleep: • Get daily exposure to sunlight, preferably earlier in the day to put the brakes on the release of melatonin, the hormone that is secreted as daylight fades.

• Exercise regularly so that your body is fatigued by day’s end.

However, don’t exercise shortly before bed.

• Limit alcohol and caffeine consumption. Alcohol may enable you to fall asleep more quickly, but research shows that it causes fragmented sleep, which means your sleep is less restorative. Caffeine, on the other hand, is a stimulant that suppresses the effect of adenosine, the chemical that TINNITUS TODAY SUMMER 2022

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makes you feel sleepy. Caffeine impacts people differently, so the guideline is to cut it out eight to 12 hours before you sleep.

Limit nicotine, which is a stimulant.

Make time for daily reflection several hours before bed. Many of us spend much of the day filtering incoming information, which means we’re apt to go to bed with unresolved thoughts and emotions. Some people find keeping a thought journal helpful.

Use a thought journal to record concerns about tinnitus and sleep, and anything else that’s bothering you. By recording your thoughts, you can evaluate whether they’re dysfunctional or not, can be resolved or not, and can put them aside so you aren’t ruminating about them when you get in bed.

Maintain a healthy diet. Both sleep and nutrition are highly complex systems that interact with one another, and research is ongoing regarding an optimal diet to improve sleep.

What is known is that a diet high in vegetables and low in sugar and processed food is better for sleep and overall health. Think Mediterranean diet. Limit sugar and high-fat foods, which can cause fragmented sleep.

Turn the lights down. Ironically, our modern lifestyle typically leaves most of us deprived of natural light during the day and overexposed to light during the evening, which makes it hard for our brains to stay aligned with our TINNITUS TODAY SUMMER 2022

internal circadian clock. Hence, several hours before bed, turn off as many lights as possible, and log off electronics at least an hour before bed. The darkness aids the secretion of melatonin, which makes us feel sleepy. Note that melatonin is a hormone, not a sedative.

• Set an alarm for an hour before you go to bed to force yourself to turn off Netflix, YouTube, or whatever else may be stealing precious minutes needed to unwind.

With each passing day, it became easier to fall asleep and stay asleep.

Over time, I gradually increased my sleep window, which eventually expanded to 10:30 p.m. to 6 a.m. Even now, I adhere to this schedule on most days throughout the year.

Sleep Hygiene and Creating Your Own Sleep Sanctuary Another key component of CBT-I is sleep hygiene—admittedly an odd term. Sleep hygiene is a set of evidence-based guidelines on how to improve and sustain quality sleep.

Although some points pertain to the bedroom itself, at its core sleep hygiene is about committing to quality sleep as soon as you wake up, beginning with getting out of bed and aligning yourself with your circadian rhythm, the internal body clock that regulates the sleep-wake cycle.

If your home is large enough, use your bedroom only for sleep and intimacy so your

brain associates that space with calm and sleep. This means no television, computers, iPads, phones, or food in the bedroom. If you have limited space, keep your workspace or recreation space separate from your bed.

• Keep your bedroom cool.

Temperature is a key factor in inducing sleep, with cooler being better than warm. Recommended temperatures are between 60 and 65 degrees.

• Furnish with a comfortable bed and pillow. Make sure your mattress suits your sleep style (back, side, or stomach) and doesn’t cause pain in your shoulders or back. If your mattress is sagging, it’s time to replace it.

• Use comfortable sheets and launder them regularly.

• Limit light. The room should be as dark as possible, so consider blinds or heavy curtains to block light from windows, a sleep mask, and motion-sensor night light.

• Use aromatherapy to create a calming environment.

• Use a sound machine to drown out noise, including the sound of your tinnitus.

• If you’re awake in bed for more than 20 to 30 minutes, get out of bed and go to another room to sit quietly, read, or meditate.

Only return to your bed when you’re tired so you reinforce the association between your bed and sleeping instead of tossing and turning.

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Daily Practices to Reduce Hyperarousal CBT is the gold standard, evidencebased nonpharmacological treatment for managing tinnitus as well as sleep, anxiety, and depression. It’s a shortterm skill-based program that works when you learn and apply practical skills to address difficult thoughts, emotions, and behaviors.

Here are three other practices that can help break the vicious cycle of hyperarousal, tinnitus, and sleeplessness: • Meditation. Research shows that meditation helps to reduce tinnitus distress, improve sleep, and promote better mental health.

• Deep Breathing. Breathing exercises to restore calm typically involve breathing in slowly through your nose, holding your breath for a few seconds, then slowly exhaling. YouTube videos demonstrate different breathing techniques.

Find the one that works for you and use it throughout the day whenever you feel tense.

• Progressive Muscle Relaxation and Mindfulness Body Scan.

Both techniques can be combined with breathing exercises and

guided imagery to instill a sense of calm and safety.

You can learn CBT-I with free or prescription apps, in telehealth appointments, and through inperson therapy. Although using a fully automated app isn’t the same as working with a therapist, I found the CBT-I app highly effective and, most importantly, motivating years afterward. It’s been more than three years since I completed the program, and I continue to use the techniques and behavioral guidelines.

I admit that it’s still hard to force myself to get out of bed on a cold morning, and I dread getting out of bed in the middle of the night to go sit in another room, but it works.

By consciously connecting daytime activities with good sleep, it’s been easier to commit to morning exercise, coffee in the morning only, light evening meals, and limited alcohol consumption.

Yes, I still have the occasional sleepless night, but it happens less frequently, and when it does, it no longer triggers an avalanche of negative thoughts about the day ahead. And I’m able to structure my thoughts and behaviors so I don’t dread the next day, skip exercise, or eat things that will undermine my sleep that night.

If it feels intimidating to commit to global changes with CBT-I, then approach it incrementally and without

negative self-talk. And if you haven’t discussed your sleep issues with your physician, make an appointment before trying CBT-I because your sleep issues could be related to an underlying medical condition or a medication that’s disrupting your sleep; don’t assume that it’s just tinnitus that is keeping you awake.

Included in the American College of Physicians’ 2016 decision was a recommendation that when CBT-I wasn’t effective clinicians should use a shared decision-making approach with patients to discuss the benefits, harms, and cost of short-term use of pharmaceuticals, which have low-quality evidence of effectiveness (“lack of evidence” doesn’t mean ineffective). A year later, the American Academy for Sleep Medicine issued a clinical practice guideline for use of specific pharmaceuticals to treat insomnia, because CBT-I isn’t always accessible or effective for everyone. It should be noted that pharmaceuticals do not replicate natural sleep, have potential side effects, and are intended for short-term use.

Letters to the ATA The ATA encourages readers to send comments and questions about tinnitus and/or articles to editor@ata.org. Emails selected for publication may be edited for brevity, clarity, and grammar. www.ATA.org

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Food Can Promote Better Sleep

Answered by Marie-Pierre St-Onge, PhD

Diet and sleep are interlinked, as evidenced by cravings for junk food when we’re tired and greater satisfaction with healthy foods when we’re well rested. Cravings for unhealthy foods can be traced to fluctuating hormones that are affected by sleep, such as ghrelin—the hunger hormone—which increases when we’ve slept too little. So, can we eat to promote better sleep, which in turn helps us stick to a healthy diet, thereby perpetuating a positive healthy cycle?

Question: What foods should we eliminate from our diet if we tend to suffer from poor-quality sleep?

Marie-Pierre St-Onge, PhD: Reducing consumption of foods high in sugar and saturated fats would be one beneficial step. Also, paying attention to the timing of eating is important.

I would recommend avoiding large meals late at night and leaving a two-

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to three-hour window between your last meal and bedtime.

Question: Is it better to focus on a quality diet, like the Mediterranean diet, as opposed to eating specific foods, such as tart cherries or kiwis, that have been shown to improve sleep?

MS: I would recommend following an overall high-quality diet that includes those specific foods as well, since there is research supporting a benefit.

So, I would include tart cherries and kiwis but also focus on including more fruits and vegetables and higher-fiber foods (complex carbohydrates such as peas, beans, nuts, whole grains, and vegetables), and reducing or limiting intake of refined foods and saturated fats.

Question: Since our sleep is less restorative as we age, what can we do from a dietary standpoint to improve sleep?

MS: Besides the recommendations above, it’s important to pay attention to foods and beverages that contain caffeine. We become more sensitive to caffeine as we age and a cup of coffee at 3 p.m. could be fine at age 30 or 40, but at age 60 this may interfere with sleep. Alcohol is also something to take into consideration, especially if disrupted sleep is a problem. Alcohol is a sedative that can help one fall asleep, but, as it gets metabolized, it can lead to disruptions in sleep later at night.

Marie-Pierre St-Onge, PhD, is an associate professor of nutritional medicine and the director of the Sleep Center of Excellence at Columbia University Irving Medical Center.

She has devoted her career to studying the causal relationships between lifestyle choices and cardio-metabolic risk, which includes researching the interactions of diet and sleep.

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Resources for Building Better Sleep We spend approximately 30 percent of our lives asleep, so understanding more about the nuances of sleep isn’t just helpful but potentially life-altering, since sleep underpins our mental and physical health.

The resources listed here are intended to provide more information about the science of sleep, sleep disorders, and ways to cultivate more restorative sleep. This is not a definitive list or intended to serve as a substitute for seeking professional help to manage sleep and tinnitus.

If you have ongoing sleep trouble, it is highly recommended that you consult your physician to discuss possible underlying causes and solutions.

Free Guides and Other Educational Resources • The Your Guide to Healthy Sleep patient booklet is available online from the National Institutes of Health at https://www. nhlbi.nih.gov/resources/yourguide-healthy-sleep.

• The American Academy of Sleep Medicine provides patient information on all aspects of sleep at https://sleepeducation.org/.

• The Sleep Foundation has extensive information on all facets of sleep, from sleep research to tips on buying mattresses and www.ATA.org

pillows. They also have a free two-week program and handbook to improve sleep. For more information, see https://www. sleepfoundation.org/.

• For guidance on finding a sleep specialist, see https://www. sleepfoundation.org/sleep-clinics/ how-to-find-sleep-doctor.

Free and FDA-Approved CBT-I Apps Note that you should consult a physician before undertaking cognitive behavioral therapy for insomnia (CBT-I) because sleep restriction can worsen preexisting medical conditions or cause safety problems for those in jobs that require focus, such as air traffic controllers, long-distance truckers, and factory workers.

CBT-i Coach U.S. Department of Veterans Affairs (VA) Free; iOS and Android

CBT-i Coach is a free evidencebased app created by the U.S. Department of Veterans Affairs in partnership with Stanford University Medical Center, the Department of Defense, and the VA Sierra Pacific Mental Illness Research, Education, & Clinical Center. The app is recommended for use in conjunction

with working with a sleep therapist.

However, it can also be used alone.

For more information, see https:// www.ptsd.va.gov/appvid/mobile/ cbticoach_app_public.asp.

Insomnia Coach US Department of Veterans Affairs (VA) Free; iOS and Android

Insomnia Coach is a fully automated app that can be used alone or as a supplement to professional help. The CBT-I program is designed to be used daily for five weeks and has features to help you track your sleep once you’ve completed the training. To download the free app, see https://www.ptsd.va.gov/ appvid/mobile/insomnia_coach.asp.

Somryst Pear Therapeutics Inc. Prescription; iOS and Android

Somryst is an FDA-authorized prescription app for people with chronic insomnia. The program can be accessed through your healthcare provider, or a provider registered with Somryst.

Support options include in-person or telemedicine appointments, depending on your location. Discount codes are available through customer support.

For more information, see https://www. somryst.com/why-somryst/.

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Tinnitus Books With Chapters on Sleep

Books for the General Public

Living With Tinnitus and Hyperacusis, by Laurence McKenna, PhD, David Baguley, PhD, and Don McFerran, MD, from Sheldon Press, was revised and updated in 2021. This well-regarded paperback, written by experts in the field of tinnitus, consists of three parts: defining the problem, a program for recovery, and the ways forward. The 17-page chapter on sleep covers basic sleep science and tips on addressing tinnitus at night.

The Consumer Handbook on Tinnitus, edited by Richard Tyler, PhD, from Auricle Ink Publishers, was revised and updated in 2016 and includes a thorough overview of managing tinnitus and how to find help. The 25page chapter on sleep and tinnitus was written by Laurence McKenna, PhD, and David Scott, PhD. Tinnitus Treatment: Clinical Protocols, edited by Richard Tyler, PhD, from Thieme, has a 14-page chapter on sleep written by Laurence McKenna and H. Clare Daniel. For a detailed summary of this chapter, see page 7.

Life Time: Your Body Clock and Its Essential Roles in Good Health and Sleep, by Russell Foster, PhD, Yale University Press, 2022. Foster is an internationally renowned circadian neuroscientist who wrote this timely book for a lay audience. By understanding the function of circadian rhythm, readers can improve their sleep quality. To listen to his TED talks on sleep, see https:// www.ted.com/speakers/russell_foster The Science of Sleep: What It Is, How It Works, and Why It Matters,

by Wallace B. Mendelson, MD, University of Chicago Press, 2017 Dr. Mendelson is a retired professor of psychiatry and clinical pharmacology at the University of Chicago. His 40-year career included serving as director of the sleep laboratory at the National Institute of Mental Health Intramural Program and director of the Sleep Disorder Center at the Cleveland Clinic.

This easy-to-understand publication blends evidence-based research with clever design that includes ample use of photos and sections on a broad range of topics, including how sleep

evolved in the animal kingdom, sleep in space, and hormones and sleep.

Why We Sleep: Unlocking the Power of Sleep and Dreams, by Matthew Walker, PhD, Scribner, 2017 Dr. Walker is director of the Center for Human Sleep and Science at the University of California, Berkeley, and a prolific speaker on the topic of sleep and the health consequences of poor sleep. This New York Times bestseller is a deep dive into what’s been discovered in sleep science over the last 20 years. You can delve into Walker’s sleep science world through The Matt Walker podcast by visiting https://themattwalkerpodcast. buzzsprout.com/ or listen to an extensive catalog of his TED Talks, available through the following link: https://www.ted.com/speakers/ matthew_walker.

Sleep Through Insomnia: End the Anxiety and Discover Sleep Relief With Guided CBT-I Therapy,

by Brandon Peters, MD, Sourcebooks, 2020 The book is a six-week self-guided program intended to provide an accurate overview of CBT-I and to be used in conjunction with support from a therapist or physician.

Support the American Tinnitus Association by Shopping at When you’re shopping for friends and family on Amazon, the American Tinnitus Association hopes you’ll link your shopping account to , the online retailing company’s generous program that enables you to shop and contribute to your favorite nonprofit organization at the same time. Amazon pays all program expenses and donates half of a percent of the cost of your eligible purchases to your favorite earmarked charity. Won’t you choose the American Tinnitus Association to help us advance tinnitus research and treatments? https://smile.amazon.com/ch/93-0749558 22

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TINNITUS RESOURCES 

13 Tips to Improve Quality Sleep With a good night’s rest, life’s problems seem manageable; without it, life—no matter what the backdrop is—feels more complicated, more daunting, and far less pleasurable.

Worse yet, poor sleep has been shown to contribute to obesity, disrupted hormones and blood sugar levels, and shortened life span.

So, what’s the key to getting a good night’s sleep? Although biological necessities cannot be ignored, there are lifestyle choices that can improve our quality of sleep, according to the National Heart, Lung, and Blood Institute, which is part of the National Institutes of Health.

• Stick to a sleep schedule.

Go to bed and wake up at the same time each day—even on the weekends. Keeping to a regular sleep schedule, according to the leading scientific sleep expert Matthew Walker, PhD, is the most impactful thing we, creatures of habit, can do in addition to exercise to improve restorative sleep. Walker advises setting an alarm clock to go to bed, so you don’t deviate from your sleep schedule by more than 30 minutes.

• Exercise.

Try to exercise at least 30 minutes on most days, but not later than two to three hours before your bedtime. If www.ATA.org

you’re able to exercise in the morning, that’s also been shown to improve sleep quality.

• Avoid caffeine and nicotine.

The stimulating effects of caffeine in coffee, colas, certain teas, and chocolate can take as long as eight hours to wear off completely. Some people are more sensitive to caffeine, so cutting it out earlier in the day is recommended. Nicotine is also a stimulant that should be avoided at nighttime.

• Avoid alcoholic drinks before bed.

A “nightcap” might help you fall asleep, but alcohol keeps you in the lighter stages of sleep, which decreases REM sleep.

You also tend to wake up in the middle of the night when the sedating effects have worn off.

Alcohol also can interfere with breathing, causing you to snore or experience sleep apnea.

• Avoid large meals and beverages late at night.

A light snack is okay, but a large meal can cause indigestion that interferes with sleep. Drinking too many fluids at night can cause you to awaken to use the bathroom.

• If possible, avoid medicines that delay or disrupt your sleep.

Some commonly prescribed heart, blood pressure, or asthma medications, as well as some over-the-counter and herbal remedies for coughs, colds, or allergies, can disrupt sleep patterns. Check with your physician or pharmacist to see if any of your medications may be undermining your sleep and ask if they can be taken at earlier times of the day.

• Don’t take naps after 3 p.m.

Naps can boost your brain power, but late-afternoon naps can make it harder to fall asleep at night.

Also, keep naps to under an hour.

• Relax before bed.

Take time to unwind. A relaxing activity, such as reading or listening to music, should be part of your bedtime ritual.

• Take a hot bath before bed.

The drop in body temperature after a bath can help you relax and feel sleepy.

• Maintain a relaxing sleeping environment.

Get rid of anything in your bedroom that might distract you from sleep, such as noises, bright lights, an uncomfortable bed, or a TV or computer. Also, keeping the temperature in your TINNITUS TODAY SUMMER 2022

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bedroom on the cool side can help you sleep better.

• Get sunlight exposure.

Daylight is key to regulating daily sleep patterns.

Try to get outside in natural sunlight for at least 30 minutes each day, preferably in the morning. Sunlight signals to your brain to stop producing

melatonin, the hormone that regulates the sleep-wake cycle.

• Don’t lie in bed awake.

If you find yourself awake after staying in bed for more than 20 minutes, get up and do some relaxing activity until you feel sleepy. The anxiety of not being able to sleep can make it harder to fall asleep.

• See a physician if you continue to have trouble sleeping.

If you consistently find yourself

feeling tired or not well rested during the day, despite spending enough time in bed at night, you may have a sleep disorder. Your family physician or a sleep specialist should be able to help you.

Slightly revised from NIH’s In Brief: Your Guide to Healthy Sleep: https:// www.nhlbi.nih.gov/resources/briefyour-guide-healthy-sleep

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Curating Sounds for Better Sleep Tinnitus masking and relief from the effects of tinnitus at night may be provided by a range of products that fit a variety of sleep situations and individual preferences. The list below represents only some of the products patients and practitioners have recommended.

The American Tinnitus Association does not endorse products, so please review the return policy for any product you might consider, as well as customer reviews.

Sound Machines For those who like white noise sounds, consider the LectroFan highfidelity white noise machine, with 20 nonlooping fan and white noise sounds, or the Big Red Rooster white noise machine. HoMedics offers white noise and nature sound options. For people who prefer the softer sound of pink noise, consider Yogasleep Dohm, which has both white and pink noise options.

play a wide range of hypnotic music, white noise, and nature sounds to help facilitate sleep. For more information, see https://www.soundpillow.com/.

Dreampad Sleep pillows have bone conduction speakers embedded in the pillow so you can connect it to any Bluetooth device and stream whatever sounds or music help you relax and sleep. For more information, see https://dreampadsleep. com/collections/pillows.

Bose Sleep Buds II play sounds using the Bose app, and though it cannot be customized, software updates include expanded sound options. Bose is well known for its noise-canceling headphones, but these buds do not cancel sound but rather provide masking. For more information, see https://www.bose. com/en_us/products/wellness/noise_ masking_sleepbuds/noise-maskingsleepbuds-ii.html.

SleepPhones, sometimes called ear pajamas, have speakers embedded in a headband so that you can listen to whatever sounds you find pleasing.

They also offer the Sleep Sounds by AcousticSheep® app, which learns what soundscapes work the best at inducing and maintaining sleep for users. For more information, see https://www.sleepphones.com/.

Sleep Pillows, Buds, and Headbands Sound Pillow offers a hypoallergenic pillow with embedded speakers that

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SCIENCE & RESEARCH NEWS

Good Sleep Supports Successful Tinnitus Management Summary by John A. Coverstone, AuD

Sleep is a necessary part of our day.

Without it, cognitive function declines, mood and behavior change for the worse, overall health suffers, and memory formation is stunted. It is not a surprise that most clinicians agree poor sleep is detrimental to coping with tinnitus.

Four researchers from National Keng Chung University and the Ministry of Health and Welfare in Taiwan studied 1,610 patients with tinnitus for poor sleep quality and its psychological effects.1 Those included in the study must have had tinnitus for at least six months—a standard length of time by which tinnitus is considered chronic—had no known cause of tinnitus from personal injury or disease, and no diagnoses of mental health conditions that were treated with medication. The last criterion helped eliminate the potentially confounding effect of mood-altering drugs.

Tinnitus was assessed using the Tinnitus Handicap Inventory (THI), a 25-item questionnaire indicating 26

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tinnitus severity. Quality of sleep was measured with the Pittsburgh Sleep Quality Index (PSQI), which uses 19 questions to assess sleep quality, latency (how long it takes to get to sleep), duration, efficiency, and disturbances. Daytime sleepiness was also measured using the Epworth Sleepiness Scale (ESS) and the Hospital Anxiety and Depression Scale (HADS) was used as well.

The average THI score was in the range of “slight tinnitus,” indicating that handicap was low overall.

Nonetheless, almost 71 percent of patients with tinnitus had sleep difficulty as measured by the PSQI. Not surprising, 43 percent of patients had abnormal daytime sleepiness.

The HADS indicated that 42 percent of patients had anxiety and nearly 25 percent of patients had depression.

For patients without sleep difficulty, age was the only factor that correlated with tinnitus severity. It is possible that this is due to the overall low severity of tinnitus among patients in this study, as a higher overall severity would likely include more patients with greater tinnitus distress. However,

patients with sleep difficulty had tinnitus handicap scores that indicated that patients experienced daytime sleepiness, anxiety, and depression.

These results indicate that patients with tinnitus who are not getting quality sleep are at significant risk of having daytime sleepiness, anxiety, and depression. This is not to say that lack of sleep causes anxiety and depression (although it certainly causes daytime sleepiness). Instead, poor sleep may result in difficulty dealing with all these conditions. It is also possible that the reverse is true— that anxiety and depression combined with tinnitus make it difficult to get quality sleep. In either case, these data allow clinicians treating patients with tinnitus to focus on sleep as an important component of management and to be aware that these conditions often affect each other, making treatment of tinnitus more difficult.

1 Y. Li, Y. Hsu, C. Lin, & J. Wu. (2022). Sleep disturbance and psychological distress in adult patients with tinnitus. Journal of the Formosan Medical Association, 121, 5. https://doi.org/10.1016/j. jfma.2021.07.022

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Does Tinnitus Anxiety Serve a Purpose?

Tinnitus and anxiety are frequently intermingled, which can amplify the ability of each to disrupt the sleep of even the most exhausted person. So, how could anxiety be a useful tool?

And how do we know when anxiety has crossed from a normal emotion into what is considered a disorder?

To help unravel the complexity of anxiety and its association with tinnitus and disrupted sleep, we reached out to Tracy A. Dennis– Tiwary, PhD, who is a professor of psychology and neuroscience at Hunter College of the City University of New York, where she also serves as the director of the Emotion Regulation Lab. She’s published more than 100 scientific articles and recently released Future Tense: Why Anxiety Is Good for You (Even Though It Feels Bad) to help people reframe their thinking about anxiety so they’re less distressed by what they’re feeling and better able to sleep.

Joy Onozuka: Anxiety is a frequent companion of tinnitus, particularly at its onset. How do you know when your anxiety has morphed into a disorder?

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Tracy A. Dennis–Tiwary, PhD: Anxiety is a normal and healthy emotion that people commonly experience. There is no “bad” anxiety, only bad ways of coping with it that can intensify anxiety to unmanageable levels. That’s why it’s so crucial to clearly understand that intense anxiety and anxiety disorders are not the same thing.

Anxiety is felt along a spectrum, from mild and barely perceptible to intense and overwhelming. Anxiety is the feeling we get when we look into the uncertain future, anticipate the possibility of something bad happening, but also understand that something good could happen instead if we work for it. Anxiety helps us imagine and care about that uncertain future and impels us to make it better.

That’s why anxiety is inextricably linked to hope. As a result, it activates us, sharpens our focus, helps us persist through obstacles and uncertainty, and motivates us to be more creative, innovative, and socially connected.

Extreme levels of anxiety aren’t enough to diagnose an anxiety disorder. Anxiety disorders are only diagnosed when an individual’s ways of coping with intense and

enduring anxiety—whether with worries, avoidance, withdrawal, or obsessiveness—are out of proportion and disrupt their ability to function in their professional and personal lives, also known as functional impairment.

So, when we say that we’re in the midst of a public health crisis of anxiety, we don’t have it quite right.

Because the problem isn’t anxiety— it’s how individuals cope with anxiety, which can lead them down the path to a debilitating anxiety disorder.

That’s not to say that we should discount the suffering anxiety disorders can cause—far from it.

Instead, we must understand that treating all anxiety as a disease hinders us from finding ways to manage and use anxiety to our advantage and from benefiting from treatments when we do need that extra support.

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JO: How do you cope with anxiety at night so that it doesn’t interfere with sleep?

TD: There are many excellent science-based techniques out there to improve sleep—everything from sleep hygiene techniques to mindfulness and sleep stories.

However, our view of anxiety and stress can block the benefits of these approaches. Many of us have come to believe the incorrect idea that anxiety is always dangerous and destructive and that the solution to its pain is to prevent and eradicate it like we do any disease, and second, that anxiety is a malfunction, a failure—of happiness and mental health—and therefore needs to be fixed.

These fallacies are unintentionally harming us because they prime us to do unhelpful things in response to feeling anxious: They make us anxious about anxiety, motivate us to avoid and suppress it at all costs, which always makes anxiety worse and blocks our ability to find helpful ways of coping. This typically results in higher levels of anxiety and more difficulty sleeping. It also stops us from being curious about anxiety.

Imagine you’ve been waking up in the middle of the night with freefloating anxiety for a couple days.

You’ve been trying to ignore it, just keep calm and carry on, but it’s getting to you. So, you decide to tune in to what your anxiety is telling you.

You go through a mental checklist: What’s been bothering me? Is it that fight I had with my partner? No, that got resolved. Is it that work deadline looming over me? No, that’s well enough in hand.

Is it that my acid reflux has 28

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gotten a lot worse and I’ve been having stomach pains for the past five days straight? Ah, there it is. Bingo.

Once you identify the source of your anxiety, you have useful information. And you now know what actions to take. When you schedule that appointment with the doctor, your anxiety immediately begins to lessen. You’re on the right track.

When you later see your doctor and get a good plan to solve the problem, the anxiety disappears. Mission accomplished. Anxiety has done its job. However, if you were to find out that there was actually something seriously wrong with your health, anxiety would return—and motivate you to take whatever additional steps are necessary to deal with the illness.

Without anxiety, you might have lost the chance to survive and thrive.

JO: If someone has a chronic condition, like tinnitus, which can be stress inducing, what would you suggest to help manage anxiety?

TD: Sometimes, anxiety doesn’t give us useful information, especially when we struggle with a chronic condition.

It’s too overwhelming and we need a break. Or there’s free-floating anxiety—that sense of angst that is so vague that it’s hard to identify what, if anything, requires your attention or what steps you should take. In either of these cases, all you can do is put your anxiety aside for safe keeping and try something different. Let anxiety go.

This doesn’t mean suppress it or erase it. Just take a break from it and go do something else.

Decades of research show the best ways of letting go: Cultivate experiences that slow you down and immerse you in the present. When anxiety overwhelms me, I might read a favorite poem or listen to music that transports me. I’ll take a walk to enjoy the beauty of the natural world, admiring magnificent trees, noticing the play of light on a building, or focusing my attention on the exquisite veining in a leaf. I often reach out to a friend who makes me feel at peace.

We can also work with—instead of avoiding—our anxiety by trying to do something purposeful with it.

Anxiety harnesses your attention and energy because it wants you to do something. And like any energy, it needs to be converted, channeled, given somewhere to go. Otherwise, the pressure builds and your quality of life takes the hit.

Anxiety is most useful when it leads you to do something purposeful.

Purpose doesn’t have to be some grand, earth-shattering mission. It just has to provide satisfaction, hope, and delight because it reflects a valued part of yourself. It gives your life meaning.

Anxiety helps you persist in your purpose, the thing you deeply care about, even when it’s hard. It fuels your momentum, unleashes your strength.

And another amazing thing about anxiety: It will naturally diminish when you take those purposeful actions. It exists so that, when you no longer need it, it can graciously step aside.

The opinions in this article have been expressed by Dr. Dennis–Tiwary in her other publications on the topic of anxiety.

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PERSONAL STORY

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Taming Unease and Tinnitus With Time, Practice, and Medication I didn’t know anxiety had a sound until I developed tinnitus.

I’ve had generalized anxiety disorder for as long as I can remember. At first it appeared in little ways; I would become sick with nerves before a test in middle school or viscerally uncomfortable at the thought of eye contact. And then, in high school, I routinely thought a plane was going to crash into my house.

Mental illness is insidious in that sense; it creeps closer to you until it rears up like a crashing wave. And while I was lucky enough to catch my anxiety early and find treatment, there have been several waves in my life.

And the one that almost swept me under was tinnitus.

I developed tinnitus in 2014 as a college student. I don’t know why.

What I know is that it fed off of my anxiety like a parasite, leaving me convinced that my life was over, that I would do something horrible as a result of my tinnitus. And while I sought therapy and developed coping skills to eventually habituate to my tinnitus, I never once considered medication for what was clearly a very dark time.

It was only years later, in the thick of the pandemic, that I made the decision to go on antianxiety medication. By then I was managing my tinnitus well and had virtually habituated to it, save for the occasional anxious thought. But it wasn’t until I started taking antianxiety medication that I realized just how attached tinnitus and anxiety can be. www.ATA.org

Once my medication kicked in, those loud thoughts about my tinnitus quieted. And in turn, my tinnitus felt quieter. More manageable. And it’s not because medication helped my tinnitus specifically. It’s because medication helped my anxiety, and for me they’re closely linked. Twin flames, intertwined in so many different ways.

In a 2014 survey done by the American Tinnitus Association, 13 percent of those surveyed stated that tinnitus causes them anxiety. And 260 of those surveyed stated they had an associated condition, such as depression or anxiety. Other research even states that anxiety may be a cause of tinnitus. While there aren’t many concrete answers about these correlations, it’s clear that a meaningful number of people with tinnitus suffer from mental illness—and vice versa.

I’ve been off of my medication for a few months now, and what I notice most is that my anxiety surrounding tinnitus has returned, just as it was before. I find myself battling back those thoughts again, those little blips of What if it gets worse? and What if a brain tumor is causing it? and What if I lose my hearing?

After more than eight years of living with tinnitus I’ve learned to manage those fears, but now I can identify them for what they truly are: anxiety latching on to my tinnitus. And even though I’m dealing with them again, it’s incredible to have this new knowledge—and this new treatment. Medication isn’t for everyone, and I dealt with side effects and complications while I was on it, but

it worked for me.

And though I’m overjoyed to realize this, I can’t help but feel a wisp of sadness.

Because I remember that young college student in 2014, locked away in her room frantically searching the internet for tinnitus cures. I remember her anxiety attacks deep in the night, wondering if the rest of her life would be like this. And I wish she would have considered medication.

Medication is a highly personal choice, but it’s a choice I made, and it helped me. And so with that sadness comes relief. Though my anxiety and tinnitus are wrapped around each other, I have the power to unspool them. And though I ache for that college student crying in her bed, I can’t dwell in the past. It’s enough to be here in the present, knowing what I know now.

Because my anxiety has a sound— and though I can’t silence that, I can silence my fear.

Ellen Meny is an Emmy-winning author, content creator, and public speaker.

Originally from Baltimore, Maryland, she currently works as a television reporter. From a young age, Ellen hoped to use her writing and public speaking skills to advocate for, educate and encourage those living with mental health conditions and tinnitus—and now she does just that. You can connect with her at www. ellenmeny.com or on Instagram at @ellenmeny.

Andrea Michelle Photography

By Ellen Meny

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 TINNITUS RESOURCES

Is Melatonin a Better Alternative to Sleeping Pills?

Answered by LaGuinn Sherlock, AuD and ATA Tinnitus Advisor

Question: I’ve read that melatonin can help you with sleep. What is it, and is it potentially dangerous? I’m nervous about taking sleeping pills and hope that this is a safe option.

LaGuinn Sherlock, AuD: Melatonin is a hormone produced by the pineal gland. The pineal gland, located in the center of the brain, secretes melatonin in response to darkness, facilitating the sleep-wake circadian rhythm. The circadian rhythm is a natural cycle of changes in physical, mental, and behavioral state over a 24hour period. Production of melatonin peaks in humans between one and three years old. Melatonin secretion steadily declines over time so that by the time you’re in your seventies, you may be producing only 25 percent of the melatonin you produced when you were a young adult.1 This is one reason older adults are more likely to experience insomnia.

Many people with tinnitus report difficulty getting to and staying asleep. Sometimes the disturbance in sleep is not new but is made 30

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worse by the presence of tinnitus. It is important to note, however, that according to the American Academy of Otolaryngology—Head and Neck Surgery Clinical Guideline for Tinnitus,2 use of melatonin for tinnitus is not recommended because efficacy has not been definitively established. At the time the guideline was published, only three randomized controlled trials had been conducted to study the benefit of melatonin in mitigating the negative impact of tinnitus. One of those studies, conducted by a group of researchers at Washington University School of Medicine, reported that participants who took a melatonin supplement selfreported improvement in sleep and a reduction in self-perceived tinnitus handicap over an eight-week period.3 However, the study design did not include randomization, blinding, or placebo control, elements of study design that are critical in establishing efficacy. The other reason the clinical guideline advises against melatonin is because melatonin is considered a dietary supplement, so it is regulated less strictly by the Food and Drug Administration than prescription and over-the-counter medications. It can

cause side effects when taken with prescription medication and/or other supplements. Interestingly, melatonin is available only by prescription in the United Kingdom.

Although melatonin supplements are not classified as medication, the American Academy of Family Physicians recommends melatonin as a first-step pharmacologic therapy for insomnia.4 According to the Sleep Foundation, 0.5 to 5 milligrams “appears to be safe and effective” for daily use to help you sleep.

Because dietary supplements are not strictly regulated by the FDA, there can be variations in ingredients between supplements. Third-party organizations, such as NSF and USP, test supplements to verify that the supplement contains the ingredients and the amount of each ingredient as listed on the label and to ensure the supplement is free of unacceptable levels of contaminants. However, third-party organizations do not verify claims of effectiveness.

Alternatives to melatonin include yoga, physical exercise, cognitive www.ATA.org

TINNITUS RESOURCES 

behavioral therapy, acupuncture, mindfulness, and nutritional therapy with functional foods that contain melatonin, such as milk, tart cherries, goji berries, eggs, milk, fish (especially oily fish such as salmon and sardines), and nuts.

Ultimately, it is your choice.

It’s important to keep in mind the following: (1) melatonin can cause daytime drowsiness, so avoid driving within five hours of taking it; (2) melatonin can interact with other prescription medications, so talk to your doctor before taking it; and (3) choose a brand that has a third-party seal of approval such as from USP or NSF. The mention of any non-federal entity and/or its products is for informational purposes only, and not to be construed or interpreted, in any manner, as federal endorsement of that nonfederal entity or its products.

LaGuinn Sherlock, AuD, is a licensed audiologist with over 30 years of clinical and research experience.

She started her career at Johns Hopkins Hospital, then spent nearly 20 years working at the University of Maryland Medical Center, home of one of the first tinnitus specialty clinics in the country. She currently works for the U.S. Army Public Health Center, in the Hearing Conservation and Readiness Branch, with duty at Walter Reed National Military Medical Center. Over the course of her career, she has provided clinical care to thousands of patients with tinnitus and has been involved in numerous research studies related to amplification, hearing protection, tinnitus, and hyperacusis. She has served on the board of directors of the American Tinnitus Association and continues to serve as an advisor with ATA’s Tinnitus Advisor Program.

1 F. Waldhauser, H. Frisch, M. Waldhauser, G. Weiszenbacher, U. Zeitlhuber, & R. Wurtman. (1984).

Fall in nocturnal serum melatonin during prepuberty and pubescence. The Lancet, 323(8373), 362–365.

2 D. E. Tunkel, C. A. Bauer, G. H. Sun, et al. (2014).

Clinical practice guideline: tinnitus. Otolaryngology— Head and Neck Surgery, 151(2 Suppl.), S1–S40.

3 U. C. Megwalu, J. E. Finnell, & J. F. Piccirillo. (2006).

The effects of melatonin on tinnitus and sleep.

Otolaryngology—Head and Neck Surgery, 134(2), 210–213.

4 E. Matheson & B. L. Hainer. (2017). Insomnia: Pharmacologic therapy. American Family Physician, 96(1), 29–35.

Speak with your physician before taking nonprescription herbs, supplements, or other medications intended to facilitate sleep, since they can interfere with other medications or affect other health problems.

Sleep medications are intended for short-term or intermittent use, while adhering to principles of good sleep hygiene. If you’re experiencing ongoing sleep issues, speak with your physician about seeing a sleep specialist.

A Sleep Diary Can Transform Your Life If you’re having difficulty sleeping, keeping a sleep diary can be helpful when speaking with your physician and for maintaining habits that promote better quality sleep. If you’re working with a sleep specialist, use the format that is recommended by that professional. If you’re keeping a personal record, consider the various options online. You can download the Sleep Foundation’s sleep diary for free

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using the following link: https://www. sleepfoundation.org/sleep-diary.

Beyond what time you go to bed and wake up, a sleep diary can include notations on a broad range of categories, including quality of nightly sleep, factors that disrupt sleep (bathroom, pain, hot flashes, etc.), daytime naps, exercise, medication, and caffeine and alcohol consumption.

And though there are many electronic sleep trackers, including easy-to-use

apps, their accuracy can vary, which means they may not be helpful for addressing insomnia or identifying negative patterns.

In addition, keeping an analog sleep journal—a handwritten one on paper— can reduce your exposure to blue light, which is known to disrupt sleep, and accrue the mental and emotional benefits to creativity and memory of putting your life in perspective on paper.

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SCIENCE & RESEARCH NEWS

Does Gender Matter When It Comes to Tinnitus and Insomnia?

Summary by John A. Coverstone, AuD

Those with long-term tinnitus know that the sound they hear often fluctuates from day to day. This is frequently due to psychological factors such as stress and anxiety or to dietary influences such as salt consumption. Another common influence on tinnitus is sleep. In some people with tinnitus, getting less sleep makes tinnitus worse.

In turn, worsened tinnitus causes problems getting to sleep, which exacerbates tinnitus in a vicious cycle that, for many people, can be broken only with pharmacological or other help getting to sleep.

A group of researchers associated with the Outpatient Clinic for Sleep Disorders and Tinnitus at Paracelsus Medical University in Nuremberg, Germany, studied the characteristics of patients with both tinnitus and insomnia, particularly as these conditions relate to gender.1 Subjects were drawn from their

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patient files and included 33 women and 43 men with tinnitus, all described as “middleaged” (average age 55 and 56, respectively). Of these, 23 women and 26 men were also diagnosed with insomnia. All patients were examined by psychologists and completed multiple questionnaires regarding tinnitus, psychometric tests, and demographic profile.

A number of gender differences were found from the data. Women were more likely to report an increase in tinnitus loudness when feeling stress, and more women than men reported feeling anxious. Women more often reported decreased tolerance of loud sounds and more difficulty localizing sound in their environment. Women were also more likely to have their tinnitus masked temporarily by environmental sounds.

Men were more likely to report the sudden onset of tinnitus, whereas women were more likely to report a gradual onset. Men reported more inactivity because of tinnitus but were better able to ignore it if there was an activity that engaged their attention.

Men diagnosed with both tinnitus and insomnia expressed higher levels of depression but also indicated they believed they could cope with tinnitus more than women did.

The research team concluded that these trends may indicate benefit in a gender-based approach to tinnitus management. Specifically, men may benefit from treatment of depression, while women might benefit from stress management and treatment of anxiety and sound tolerance. By using data such as this, clinicians treating patients with tinnitus may be able to more quickly identify individual influences and provide targeted treatment for each patient.

1. K. Richter, M. Zimni, I. Tomova, et al. (2021).

Insomnia associated with tinnitus and gender differences. International Journal of Environmental Research and Public Health, 18, 3209. https://doi. org/10.3390/ijerph18063209

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 PERSONAL STORY

Counting the Days of My New Normal

By Jordan Maddex–Kopp

Reflections on a Hot Take I wrote a thing. A while back. I wrote it while bloody deep in the grips of fear, fatigue, and uncertainty.

That thing I wrote is included here.

It is personally difficult to read, as I am not yet so far into my new normal that I don’t recall what it was like before the shattering of silence—before the introduction of that high-pitched harbinger that is tinnitus.

But reflecting on the time I wrote it, on the feelings that built and swelled as I bounced from doctor to doctor and from one sleepless night to the next, I am staggered by the human ability to adapt with time. Not perfectly, not without discomfort, not without some unwanted adjustments, but to adapt, nonetheless.

Coming up on more than a year since my sudden-onset tinnitus, though the severity—and the invisibility—of my pal T remains, my ability to cope and manage through this experience has slowly come into focus. At least, come more into focus—which is why I am offering this “prelude” to the far more direct and emotionally heavy thoughts that rallied and poured forth in the initial months following T-day.

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Often, those with chronic conditions feel an implied or even a directed need to sanitize their experience. After much reflection, I refuse to sanitize what tinnitus is capable of putting someone through. A revisionist take on what I experienced then—and what the bad days can still feel like now— does nothing to celebrate and honor the strength needed to learn how to live a life of shared space within your own sanity.

I choose to be honest about my experience—especially about the darker corners and deeper valleys—because somewhere out there, someone else is waking up to a sudden, inexplicable roar that no one else can hear, that few can understand, that no medication can treat, and that is easily dismissed.

The truth about any chronic condition is it might never get “better.”

But your reaction to it can, in time, change, with resolve. I do not feel better. But I do feel more connected again. More capable. More in control.

My candor remains because shared experience—shared honest experience—can mean more than anything else.

And I think that is the point.

239 Days Since T Entered My Life

TL;DR April 4, 2021. The day my quiet vanished.

I’ve been stewing on this for eight months now—239 days to be exact.

Two hundred thirty-nine days of trying to find the words to explain what has happened—to justify the fear, the disruption, and the pain that has come from something invisible and unmeasurable. Something that at the surface will leave me saying, “Yes, I know it could be worse—I know other people have things far worse—I know to the outside world, I’m fine”— but it’s not fine, and I’m not fine, and the reason why is so intangible it leaves people unsure what to say.

I’ve learned a lot since April 4.

There is no cure for tinnitus.

People don’t talk about tinnitus.

And it can turn your world on its head in an instant.

Imagine a high-pitched, screaming noise. A five-alarm sort of sound.

Make it a “REEEEEEEEEE,” but with www.ATA.org

PERSONAL STORY

attitude, and some sort of unjustified spite for its host.

Now make it higher.

See every doctor. Five appointments a week. For over two months.

No, even higher.

An internist.

Even louder.

An audiologist.

Nope, louder still.

A counselor.

Now make it 24/7, on a loop, impervious to your surroundings, unreachable by medicine, and unaffected by your attempts to “mask” it with—wait for it— more sound.

Now have it take the place of sleep.

For months on end.

Have it cover and obscure and steal the familiar and comforting sounds of music, and television, and the voices of those around you.

Have it consume your thoughts, and your energy—because let me tell you, a brain without the chance to rest—a brain that is always processing and fighting a sound of its own production—is a very, very tired brain, indeed.

Have that exhaustion transfer to your body.

Have it light a flame of anxiety unlike anything you have ever experienced.

Have the panic attacks come on so suddenly, so swiftly, and so without warning that you no longer feel safe in your own skin.

Find yourself on the edge of unconsciousness, shaking with a violence that you can’t believe your body will allow for even a minute—let alone 10, or 20—unable to breathe, unable to move, unable to think, unable to do anything but lay on the floor and sob.

A physiatrist.

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An acupuncturist.

Hell, even a hypnotist.

And now get a second opinion, for each of the above, because no one has an answer.

Spoiler alert: neither does the second round.

Ask in desperation, “If I am exhausted enough, my body WILL force me to sleep, right?”

(FYI: That answer is a very loose “… Right.” Because sleep has a cumulative effect—so does the lack thereof.)

Get on a sleeping medication. Heck, take a few models out for a spin.

Get so you now can’t sleep without it.

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Get on an anxiety medication.

Make that two.

Make that three.

Do this while trying to maintain, nay, cling to your life as you know it—your sanity, your job, your relationships, your role as a fun and loving parent—with no additional hours in the day—and no escape from the “REEEEEEEEEEEE,” even at night.

Even in sleep, when the medication allows it.

The thing of it is, this is not a pity party.

This is a needed exercise of recognition, and acceptance.

This is an acknowledgment, from me, to “T.” There are two of us now, in one person. Me and this uninvited, very assertive, house-crasher of a guest.

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 PERSONAL STORY

I have to accept that my world now needs to accommodate both of us.

Which means, in some ways, I am not the person I was before my pal moved in.

There are days the sound puts us in a bubble together, blocking me from—everything.

There are days the sense of isolation is palpable.

There are days I back out of plans.

There are days I can’t bear to interact.

Not because I don’t want to.

But because the noise is especially rowdy that day, and I can’t—and don’t have the energy to—keep up.

This has been a physical and mental journey. A largely invisible one. One that I have not shared because “oh, I have some ear ringing, too” is just not going to start a conversation worth having.

Because I’ve been searching for the words for 239 days, and I know I still don’t have them right here, now.

Invisible illnesses, mental health, chronic conditions— these things exist.

So does the sense of shame that can come with them.

In my mind, this is something I *should* “just work through,” I *should* “be stronger than,” I *should* “not let get in my way.”

The days I can’t do the above, the shame is as unbearable as the noise.

I want to kick and scream and feel in control, feel like I can deliver on my

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best for everyone around me. When it’s a “bad day,” when I feel off, even if no one else can see it—man … what a head trip—because, as it happens, it IS all in my head. Ringing, screeching, wailing at something at or above 8 kilohertz (read: damn high)—in my head, reserved for me alone.

And like other unseen conditions, I assure you—this is VERY real.

I’m lucky, so lucky, to have the calm and patience of my husband and my father. To say I’ve been on a roller coaster—they have been on this ride with me.

I miss the sound of silence so very much. At least 239 days into this, I am able to say—I CAN live without it. It’s just a slightly different way of living— which will take some getting used to. I want to, and plan to, continue doing the things I love—creating, collaborating, working with my whole heart—and loving the people in my life with my whole soul.

I know somehow, this is “making me stronger.” I have reasons, many reasons, to keep trying. Will it ever get better? Maybe. Maybe not. But here, I have to err on the side of hope.

If I bail on plans or go radio silent, I’m likely stuck in the bubble that day, and I’m sorry.

If I seem like I can’t hear you—I’m trying.

It goes without saying, but in this maddening world, it still somehow needs to be said: You really never know how much someone is treading water under the surface.

If we were all a little more honest about it, imagine the network of empathy we could build.

All my  to anyone else treading out there.

#stoptinnitus If you are struggling, with something invisible OR something seen, never hesitate to reach out.

Jordan Maddex-Kopp is a full-time mother, wife, and marketer/ communicator and a part-time writer, crafter, and journaler.

Her professional career spans over two decades in graphic design, content creation, social media management, and leadership of award-winning in-house marketing teams. Outside of work, Jordan remains active in several professional associations. She has served five years on the Board of the Omaha Chapter of the American Marketing Association (bringing home the top AMA Award in the country, the AMA Gold Chapter of the Year, for her presidential term in 2019–2020) and is a founding board member for Women Leading Travel and Hospitality. She is also a two-time 40-Under-40 Award Winner (Midlands Business Journal and Direct Marketing News/DMN).

Her husband, Mike, and son, Chase, are the lights of her life and have been tremendous support since the sudden onset of her tinnitus in April 2021. She took up journaling in the early fall of 2021 as a coping mechanism, and operates the Instagram channel @jmk_journal to document her work.

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PERSONAL STORY

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Countless Days Exploring Tinnitus Coping Strategies

By Jordan Maddex-Kopp

My experience with tinnitus is not uncommon, but some of my coping mechanisms might be! So much of the tinnitus coping experience is experimentation—adapting to changes in your own, individual soundscape and looking for new ways to combat and work through the noise. My approach to tinnitus management has relied heavily on the coping mechanisms below, a combination of modern solutions and old-fashioned making. In the face of a chronic condition, it is certainly great to have options.

Three of my favorites (based on my personal journey!): • YouTube Playlists: Believe it or not, YouTube is brimming with specially produced music and sounds designed with tinnitus in mind. Some are specific to tinnitus of a defined frequency, some are ambient and spa-like, some are fully randomized A page from with fractal tones Jordan’s journal.

to keep your mind and brain guessing in the face of that repetitive ring. The best part?

The regularity of these various creators—unlike white noise machines or apps with preloaded sounds—offers free, new tinnitus distractions nearly every day.

Individual videos run anywhere from 30 minutes to 8+ hours (designed for use overnight).

• Creative Journaling: There is sometimes nothing more satisfying than diving into the creative process, pairing your mind and vision and sense of touch with a single task of making something beautiful.

Something about the allconsuming nature of, in my case, creating a page in my journal, completely removes the sound from any place of resonance.

In those moments, my brain is deeply connected to the texture of the paper and the vibrancy of various embellishments instead of playing tug-of-war with my tinnitus. Plus, each page of my journal affords the opportunity to focus on positive affirmations and motivational messages— which can be incredibly

important to reinforce on bad tinnitus days. (Join me in healing journaling at @jmk_journal on Instagram.)

• VR: Yes, that virtual reality—the same VR my teenager spends hours in daily, hooting and hollering along with his friends while playing thrilling titles like Gorilla Tag. I got swept into the VR world one evening after a few cocktails at home, when my husband and I decided a friendly competition in the music rhythm game Beat Saber was in order (I won). Much like my journaling habit, VR offers a near total (albeit temporary) escape from tinnitus—sight, sound, and movement are aligned in a glowing, immersive environment. You’re fighting crime, you’re in battle with aliens on a distant planet, you’re slicing and dicing glowing orbs to the beat… you simply have no time to focus on your tinnitus. I have found enough value in the escape of virtual reality to invest in my own VR headset so as not to fight over game time with my teen (I plan on besting him in Beat Saber next!).

We All Need Support to Thrive Without meaningful support and use of effective interventions, living with tinnitus can be challenging. If you’re struggling with tinnitus or have tinnitus management questions, please call the ATA’s Tinnitus Advisors Program at 800–634–8978, ext. 3.

www.ATA.org

To find a community that understands your struggles, consider joining a tinnitus support group that meets in person or online. Listings can be found on page 48 and on the ATA website, www.ATA.org.

It should be noted that tinnitus

support services are not intended as a substitute for seeking therapy or medical help.

If you are experiencing thoughts of suicide, please call or text 988, which will connect you with a trained crisis counselor in your area.

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ATA NEWS

Tribute to Undaunted Pioneers

Leader, Teacher, Mentor, Scientist, Clinician, Patient Advocate, and Man of Faith

David M. Baguley March 18, 1961, to June 11, 2022

By Kevin J. Munro, Michael A. Akeroyd, and Judith C. Bird, with grateful thanks for contributions from colleagues and friends

The sudden and tragic death of David (Dave) Baguley has left a gap in the national and international audiology and hearing science community.

Dave was a passionate and gifted scientist, confident and sure in his research; for many of us, he was the go-to person for the latest research findings. He published around two hundred scientific articles and two books, most recently the updated edition of Living With Tinnitus and Hyperacusis. He was a five-time winner of the Marie and Jack Shapiro Prize from the British Tinnitus Association, and won the Norman Gamble Research Prize from the Royal Society of Medicine Section of Otology, the TS Littler Prize of the British Society of Audiology, and the International Award in Hearing of the American Academy of Audiology.

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A Mancunian and lifelong supporter of Manchester City Football Club, he was awarded a BSc in psychology, 1983, then an MSc in clinical audiology,1985, both from the University of Manchester.

He started his career at the MRC Institute of Hearing Research, Cardiff, then moved to the NHS, working as a clinical scientist in audiology at Addenbrooke’s Hospital, Cambridge, where he remained for over 30 years.

While in Cambridge, he rose to consultant status and then head of audiology services and cochlear implants. During this time, he was awarded an MBA (distinction), a PhD on physiological mechanisms of tinnitus in vestibular schwannoma, and a diploma in pastoral theology. He built a formidable international reputation as a leading expert in tinnitus and hyperacusis, publishing prolifically on the subject, and receiving referrals from all over the country. This was in no small part due to his empathic approach to his patients.

In 2016, Dave relocated to the University of Nottingham, where he took up the position of Professor of Hearing Sciences in the School of Medicine’s Division of Clinical Neuroscience and investigated hearing loss and tinnitus.

Dave was a voracious reader and an innovative thinker. He managed to bridge professional boundaries, connecting people with overlapping interests and linking ideas and clinical strategies from different specialties.

He was one of the few who comfortably straddled audiology, ENT, and hearing science communities, exchanging insights and perspectives.

His clinical background and ongoing, clinical consultations meant he developed a clear line of sight from discovery research to patient benefit.

He was much in demand as a speaker on tinnitus and audiology courses around the world, with an eloquent, relaxed, and easy style— plus the ability to give a thoughtful response to questions from the floor. www.ATA.org

ATA NEWS 

He was able to combine art and science, often incorporating literary references into his presentations.

Throughout his career, he worked with impressive efficiency and juggled commitments at the local and the national level. He invested time in supporting and promoting the profession. He served the British Society of Audiology as chair, 2009– 2011, and was editor of the British Journal of Audiology (now International Journal of Audiology) from 1995 to 2000. He helped establish the British Academy of Audiology, cochairing the inaugural conference in Manchester, 2004. Dave joined the editorial board of what was then called ENT News in 2008 and, campaigning fiercely so that audiology content would have

equal coverage in the magazine, was instrumental in inserting the word “Audiology” into its title (it’s now ENT & Audiology News). He was president of the British Tinnitus Association, 2015–2019.

Dave earned an international reputation as an audiologist and hearing scientist. As evidence, he played an important role in the formation of the international committee of the American Academy of Audiology, serving as cochair for three years.

At his core, Dave was a man of deep Christian faith. He was ordained a deacon in the Church of England in 2011 and priest the following year.

Called to ministry alongside his clinical role, his correct title, although

29th Annual International In-Person/Online Conference

Management of the Tinnitus & Hyperacusis Patient

rarely used by those who knew him, was Reverend Professor. He was associate minister at Saint Martins, Sherwood in Nottingham. Outside of work, he was a great cook, a lover of live music events, a hill walker, an avid reader, enjoyed “shooting the breeze” with friends, spoke warmly and lovingly of his family, and indubitably possessed a remarkably eclectic collection of shirts.

He is survived by his wife Bridget, whom he married in 1989, and their two sons, Sam and Luke, and daughter, Naomi, all of whom he was immensely proud. The audiology and hearing science community remember each of them, and the extended family, at this time.

ATA is a o be proud t

ND DIAMO OR SPONS

The 29th Annual International Conference, Management of the Tinnitus & Hyperacusis Patient is scheduled to be held August 11-12, 2022, at the University of Iowa. The educational event is intended for otologists, audiologists, hearing aid specialists, and other healthcare professionals providing clinical services for tinnitus patients. Topics include an overview of current evaluation practices, management strategies, and research. Presentations are given by leading researchers, practitioners, and leaders in advocacy and include the latest developments in the areas of medical treatments, neuroscience, sleep therapy, noise-induced hearing loss, and hyperacusis.

The conference, which is being held in person and online, is intended to increase the knowledge and skills of clinicians; however, it is open to patients and their families, with the understanding that no individual diagnosis or treatment will be offered.

For more information, visit the University of Iowa’s website: https://medicine.uiowa.edu/oto/education/ conferences-and-events/international-conference-management-tinnitus-and-hyperacusis

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ATA NEWS

Courtesy of Hyperacusis Research

Tribute to Undaunted Pioneers

Advocate for Hyperacusis Patients and Research

Bryan Pollard June 25, 1964, to May 4, 2022

We are deeply saddened by the death of Bryan Pollard, founder of Hyperacusis Research, cofounder of the Quiet Coalition, and former board member of the American Tinnitus Association. Bryan suffered from hyperacusis, a condition in which everyday sounds are perceived as excessively loud and sometimes painful. Rather than just learning to live with it, he started an all-out effort to find a cure as quickly as possible. As he explained in an email in 2013: I must apologize first of all for not acknowledging the great history of research that has enabled us to have the current level of understanding of the auditory components. Having worked in the semiconductor industry for two and half decades where we started with 5+ µm transistors and now we’re at 0.014 µm transistors, I certainly appreciate the long technical 40

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journey. I also appreciate even more the complexity of the whole system as ARO [the Association for Research in Otolaryngology conference] was somewhat like a mini course for me since I’ve only been studying the auditory system in an informal way the past 4 years and haven’t taken formal classes. While I’ve studied many 100s of papers and various textbooks, I know nothing replaces formal training. I’m trying to learn enough to work with scientific advisors to understand where the gaps in research lie to try to ensure our small, targeted funding we provide over the next few years will help drive the right direction for hyperacusis research.

As far as I could surmise, Bryan spent all his free time and effort trying to find a cure and raise awareness about the devastating effects that severe hyperacusis can have on a person’s life, mental health, and social

and family interactions. He organized meetings where patients could gather to discuss their loudness intolerance problems and learn about current research and where they might seek treatment. He applied his engineering problem-solving skills to bring together distinguished researchers and clinicians to review the scientific literature for the past two hundred years and publish their findings in scientific journals describing four common forms of the disorder: loudness hyperacusis, annoyance hyperacusis, fear hyperacusis, and pain hyperacusis.

Courtesy of Hyperacusis Research

By Richard Salvi, PhD

Richard Salvi, PhD, and Bryan Pollard at an ARO meeting. www.ATA.org

ATA NEWS 

the National Institutes of Health to make them aware of the hearing healthcare problems of young and old patients with debilitating hyperacusis and helped to convince the National Institute of Deafness and Other Communicative Disorders that the disorder needed research funding.

Many hyperacusis patients made personal contact with Bryan to explain their hearing issues; these interactions helped increase his understanding of the problem and provided opportunities to refer them to clinicians or scientists whom they could contact.

Bryan was a kind, thoughtful, and caring human being. His dedication and commitment to his nonprofit Hyperacusis Research set the wheels

in motion for this important work to be continued under the strong leadership of Michael Maholchic, president, and other distinguished members of the board of directors. Please visit https://hyperacusisresearch.org/# for more information.

Courtesy of Hyperacusis Research

To promote research in the field, he initially gathered scientific researchers together in informal meetings at the ARO annual conferences. Working with members of the scientific community, he stepped up his efforts to organize formal sessions on hyperacusis at the ARO event. At these meetings, he organized dinners and informal gatherings where he introduced scientists to hyperacusis patients and their families—efforts designed to build partnerships between the public and clinicians and researchers.

Bryan was a prolific fundraiser; he set up a website to solicit donations and sought funding from corporate sponsors, private foundations, and other donors. He met with staff at

From left: Betsy Maholchic, Leslie Liberman, Charlie Liberman, PhD, Bryan Pollard, and Michael Maholchic at a Mass Eye & Ear event in 2017.

Share Your Story With ATA Readers Every day, people struggling with tinnitus turn to personal stories to understand what the future might hold. The stories are honest and don’t sugarcoat the challenges and time it often takes to learn how to manage and live with tinnitus.

If you have tinnitus and hyperacusis, we’d like to hear from you. We’re also looking for stories from people who have tried various treatments and/or products for tinnitus relief. Please send your story to editor@ata.org by September 15. Suggested word length is between 600 and 900 words.

www.ATA.org

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 PERSONAL STORY

Tribute to Undaunted Pioneers

Bryan, Hyperacusis, and Me

By J. C. Cohen

My noise injury was 15 years ago, caused by too many hours in a workplace that was hazardously loud to me, but not to anyone else, and not according to any workplace standard.

Back then, there was little information about hyperacusis or noise injury, and most of what there was was wrong.

Most everything online said not to “overprotect” your ears, whatever that meant.

I disregarded the advice. It was so obviously wrong. I was in such severe, constant pain that I could barely function. I couldn’t leave home without protective earmuffs, the kind construction workers wear. My cat’s meow felt like a needle piercing my eardrum. The newspaper’s rustling pages, the toilet’s watery flush, the swish of nylon fabric all caused additional pain.

So I was intrigued when Google yielded something new: Hyperacusis Research, a nonprofit dedicated to this rare and hidden condition that I had never heard of until it happened to me.

That’s how I met Bryan Pollard— kind, smart, thoughtful. He himself 42

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had an injury caused by a noisy woodchipper outside his house.

And he had, in his younger days, listened to very loud music. (As we know, noise damage is cumulative.) He was all too aware that pain—a key component of such an injury—was barely mentioned. He was also aware that the conventional wisdom passed around to people with hyperacusis was harmful to many. And he was determined to do something about it.

Almost single-handedly, Bryan got pain hyperacusis taken seriously by the research community. The medical community proved harder to penetrate, maybe because current medical tools and techniques aren’t sophisticated enough to detect hyperacusis, but he made inroads there, too.

His mission was not just to propel a nascent field forward. He had to turn it around first, and he did so with grace and patience. Researchers would often say you could do experiments on mice, but mice couldn’t tell you what

they felt. Well, people could.

“And they still don’t listen!”

Bryan said.

Bryan noted that the onset of hyperacusis was a turning point in people’s lives, the start of a chapter that was hard to get beyond because noise-induced pain is so disabling.

Bryan emphasized the individual and heterogenous nature of the condition, with the same noise dose having no effect on some people and causing life-ruining injuries for others.

He preferred to make his points by asking questions rather than spouting information. For example, people would sometimes say they improved because they stopped wearing ear protection. In fact, they stopped wearing ear protection because they improved. “Which is the cause and which is the effect?” he often asked.

He coined the term “noise-induced pain,” modeling it after “noiseinduced hearing loss,” a phrase well understood in the clinical community.

Bryan’s specific focus was noiseinduced hyperacusis—which goes along with tinnitus and aural fullness— www.ATA.org

PERSONAL STORY

though he included hyperacusis from other causes, such as ototoxic medications and head or neck injuries.

Hyperacusis is complicated. It has a dozen definitions. In brief, every sound is perceived louder than it should be. It is almost always accompanied by tinnitus, as well as aural fullness, a subject that is completely unresearched. Hyperacusis and tinnitus exist in an ever-changing competition vying for the horrific honor of which is worse. This may be because both come with an enormous gradient of severity. Hyperacusis starts with sound seeming abnormally loud and continues to nonstop ear pain, even in silence. Severe hyperacusis is a form of chronic, intractable pain—but it often can improve. Severe tinnitus is a noxious sensory stimulus capable of causing enormous distress—and it doesn’t always improve. Sometimes hyperacusis improves while tinnitus worsens.

Even a mild case of hyperacusis seems severe, probably because it can be life-ruining and debilitating to a vast degree. People’s descriptions of the pain are remarkably similar: a burning pain at or behind the eardrum, plus a stabbing, jabbing, icepick pain when there is noise. Like barbed wire being dragged through your brain. Like sandpaper rubbing your ear canal, or hot acid being poured in. A hot poker being thrust and twisted in your ear.

Bryan wrote several pieces for professional journals, pieces that sufferers found incredibly helpful as they faced a skeptical medical community. In “Unravelling the Mystery of Hyperacusis with Pain” (https://www.entandaudiologynews. com/features/audiology-features/ post/unravelling-the-mystery-ofhyperacusis-with-pain), he noted that www.ATA.org

the pain component had previously been completely overlooked as part of hyperacusis.

Now, pain hyperacusis is sometimes termed “noxacusis” or “auditory nociception.” “Noxacusis” has come into more common use, possibly because it is one crisp word, a combination of noxious and hyperacusis. Hyperacusis is nothing if not noxious.

And he emphasized the single most important thing for patients, which had also been overlooked: the evil of setbacks, or easy worsening with additional noise insults. He ran surveys to show that “a key to progress is to minimize setbacks.” In some cases, people rebound from a setback in days. In other cases, they never do. The medical community was not focused on the need to prevent reinjury, an issue Bryan brought to the fore. “People need to manage their noise exposure,” he would say, just as they needed to manage diabetes or any other chronic condition.

He himself managed by using earplugs and earmuffs. He would tell me of unexpected noises he encountered at work. He organized Hyperacusis Research events at ARO, the annual meeting for the Association for Research in Otolaryngology.

Some of the researchers there were surprised he was wearing earplugs, because the room “wasn’t that loud.”

True, it wasn’t. Just like walking “isn’t that hard” but people with a broken spinal cord still can’t do it.

Life with hyperacusis is hard. I have had to adjust mine enormously.

In some ways, I am lucky. I protected my ears fanatically and improved over the course of several years. I am able to talk on the phone, though I limit my phone time and am wary of harsh

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processed sound. I am able to type on a computer, though I know others get pain from the clack of keys. I have an arsenal of protective devices— earplugs, earmuffs, noise-canceling headphones—always available. I have made my home as quiet and comfortable as humanly possible, and I don’t leave home without dual ear protection. After a few years of nonstop pain, the hyperacusis has gradually diminished. And yet by any measure it is severe. My tinnitus is unpleasant but tolerable.

Bryan helped individuals as much as he could. He provided documentation that would help people get disability.

He informed people about the best options for handling a dental visit.

He cautioned people that an MRI—a jarringly loud machine—carried a high risk of permanent reinjury and a low probability of finding a fixable problem.

In a broader sense, he took the helm of a scientific advisory board comprising open-minded scientists and young researchers. The field could make no progress without maverick ideas, Bryan told me. Bryan was the greatest maverick of all. Progress is being made, at last, and only because of him. Bryan, may you rest in peace and silence.

To honor Bryan’s memory, Hyperacusis Research urges people to donate their ears to science by signing up for the temporal bone registry at Mass Eye and Ear, [https:// masseyeandear.org/tbregistry] to help scientists further their knowledge of hearing disorders. To learn more about Hyperacusis Research, see https:// hyperacusisresearch.org/

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 SCIENCE & RESEARCH NEWS

Is There a Link Between Tinnitus and Sleep Apnea?

Summary by John A. Coverstone, AuD

It is difficult to define the relationship between tinnitus and sleep disorders.

Without a large, highly controlled, and long-term study, researchers can only say that they tend to coexist and cannot say which condition may cause the other.

Researchers Malcolm Koo from the University of Toronto and JuenHaur Hwang from Tzu Chi University in Taiwan performed a population study looking at the relationship between tinnitus and sleep apnea.1 Investigating sleep apnea provides a more controlled study model because sleep apnea is caused by structural changes to the nose and throat, not by tinnitus. Therefore, if a controlled group of people with sleep apnea have an unusually high incidence of tinnitus, it would suggest that poor sleep is contributing to tinnitus.

Koo and Hwang obtained data from the Longitudinal Health Insurance Database 2000, a Taiwanese data set containing medical information for a random selection of a million people.

They selected people who had two registered diagnoses of tinnitus no more than 90 days apart. For each subject, they selected five controls who were matched by age, gender, and date of services. They looked for diagnoses 44

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of sleep disturbance and sleep apnea and other related diagnoses, including obesity, head trauma/concussion, Meniere’s disease, and sensorineural (inner ear or nerve) hearing loss, requiring two diagnoses in the same timeframe for these conditions.

They performed statistical analysis using a method called multivariate logistic regression analysis. This is a calculation that determines how likely an outcome is (tinnitus, in this case) based on multiple other factors (independent variables). When the researchers analyzed sleep disturbance and controlled for medical conditions that might cause both sleep problems and tinnitus, they found that the risk of tinnitus was 1.13 times higher for people with sleep disturbance than for those without. Looking at sleep apnea and controlling for other medical conditions, they found that the risk of tinnitus was 1.36 times higher for those with sleep apnea compared to those without the condition.

There are some limitations to this study because the diagnosis of tinnitus and other conditions is one-dimensional. The researchers restricted the data set to people with conditions that had been diagnosed at least twice to increase the likelihood that each diagnosis was accurate.

However, some questions remain,

such as whether the data set is biased toward those with more severe tinnitus because those with milder conditions might not have bothered to report it during medical visits or may not have returned and had a second diagnosis entered in the healthcare system. Similarly, diagnoses of sleep apnea and sleep disturbances depend on patients reporting these conditions.

In the case of sleep apnea, a sleep study is also required to confirm the condition while sleeping.

Nonetheless, the risk of tinnitus for people with sleep apnea is significant and suggests a relationship where poor sleep may exacerbate tinnitus or even cause a subclinical tinnitus (where the sound is present, but not heard) to become more evident and bothersome.

If you’re wondering if you have obstructive sleep apnea (OSA), complete the online STOP-Bang questionnaire, a widely used tool to assess OSA, not central sleep apnea, which is a different condition. The questionnaire can be found at http://www. stopbang.ca/osa/screening.php.

1 M. Koo & J. H. Hwang. (2017). Risk of tinnitus in patients with sleep apnea: A nationwide, populationbased, case-control study. Laryngoscope, 127, 2171–2175. www.ATA.org

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Navigating Life’s Ups and Downs With Positive Psychology The second article in a three-part series on utilizing positive psychology to thrive—not just survive—while living with tinnitus and/or hyperacusis.

By Deborah Hall, PhD

Positive psychology is a maturing branch of mainstream psychology that has evolved in a series of “waves” since it was born in 1998 in Professor Martin Seligman’s inaugural presidential address at the American Psychological Association.1 In the first of this three-part series on the topic (Vol. 47, No. 1), I introduced positive psychology as the scientific study of what makes people thrive. Dispelling some common misconceptions, I argued that positive psychology is not about Happy-ology. Well-being is much more than simply fostering positive emotions. Well-being includes skills such as having a sense of purpose, engaging in meaningful activities, being “in the flow,” nurturing positive relationships, and developing a feeling of life satisfaction, as well as character traits such as optimism, emotional stability, and resilience.

The second wave of positive psychology set an important principle by acknowledging that nobody’s life www.ATA.org

is a bed of roses. Life has its ups and downs. But by facing difficulties rather than avoiding them, by overcoming distressing experiences, or by learning to accept things that can’t be changed, individuals can grow stronger. Such encounters can provide greater selfinsight and can help to strengthen the skills and competencies to bounce back in the face of any future setbacks.

Having set the scene by recounting the scientific journey of positive psychology, I now turn to consider how positive psychology principles have been considered by experts in tinnitus and hyperacusis, in terms of scientific research and clinical practice, and I end by proposing several important research directions to start to fill the gaps in our knowledge.

Tinnitus and Hyperacusis A first step in preparing this article was to search for published academic reports in which experts have written about positive experiences living with tinnitus or hyperacusis. My search focused on two of the largest databases of academic publications: Web of Science (published by a public analytics company called Clarivate) and Scopus (published by Elsevier, an academic publisher). Collectively, these databases provide reasonably comprehensive coverage of over 170 million scholarly records. Keywords

for searching included (“tinnitus” OR “hyperacusis”) AND (“positive psychology” or “positive”).

In 2015, a review was published of positive experiences associated with acquired hearing loss, Ménière’s disease, and tinnitus.2 Of the 15 articles included in the review, only one considered tinnitus (Kentala et al., 2008). This article reported responses from over one hundred patients attending a tertiary-level tinnitus clinic in Wales.

A more recent study explored positive experiences related to living with tinnitus in 240 U.K. volunteers for a trial of internet-based cognitive behavior therapy (CBT).3 Four shared themes that gave mental, physical, spiritual, social, or emotional benefits were:

1

personal development (e.g., lifestyle and attitude changes, taking better care of their ears and hearing), support (e.g., being able to relate, empathize, help, and support other sufferers), coping (e.g., learning strategies to relieve symptoms, using symptoms to self-advantage), and outlook (e.g., having a greater desire to achieve things).

2 3 4

In these two studies, around twothirds of people reported no positive TINNITUS TODAY SUMMER 2022

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SPECIAL FEATURE

experiences at all (68% in Beukes et al., 2018; 59% in Kentala et al., 2008).

I was unable to find any articles reporting positive experiences related to living with hyperacusis.

Ménière’s Disease The paucity of clinical research on searching for positive meanings in tinnitus and hyperacusis contrasts with that in Ménière’s disease (vertigo, hearing loss, tinnitus, and aural fullness). A review described eight articles on how people living with Ménière’s disease can experience a positive effect on relationships with significant others, personal development, appreciation of life, personal strength, and spirituality.2 For example, one of the earliest studies (Stephens et al., 2007) assessed 181 postal responses from members of the Finnish Ménière Federation.

Seventy-five percent had listed positive experiences associated with their Ménière’s disorder, including learning to fulfill their own needs and to feel greater empathy with other sufferers, and developing a better understanding of the condition.

However, this was not universal.

In-depth interviews with four women living with Ménière’s disease (Talewar et al., 2020) described how they were simply “trying to get on with things.”

Ménière’s disease was not seen as a positive force in their lives despite questions explicitly probing both positive and negative experiences.

Nevertheless, engaging in treatment with a supportive clinical practitioner played an important role in fostering 46

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a positive outlook. For example, two of the interviewees described how physiotherapy helped them to live positively with Ménière’s disease. In particular, the therapists were seen as helpful if they offered hope about the possibility of living well with the condition (i.e., optimism), as well as providing face-to-face support through the most frightening aspects of the treatment (i.e., positive relationships).

Positive Is Not Simply the Absence of the Negative In the context of the academic reports on tinnitus and hyperacusis, I found that often the word positive was typically used in the context of reducing the negative, especially alleviating symptoms. Since positive psychology refers to the scientific study of what makes people achieve the highest states of well-being (and the application of those principles), this work does not quite fit into the positive psychology framework. Let’s consider two illustrative examples to explain what I mean:

Assessing the positive in tinnitus?

The Tinnitus Cognitions Questionnaire (TCQ) is unique in its claim to measure both positive and negative thoughts; it includes 13 negative items and 13 positive items.4,5 From a clinical perspective, these positive thoughts may reflect a reasonably healthy state of mind for someone coping with tinnitus, but this does not necessarily mean that a high score on the positive items indicates a state of feeling good and functioning well. This is because many of the positive items start from a position

Positive psychology therapies focus primarily on building the skills to flourish and thrive.

Cognitive behavior therapy (CBT) and Acceptance and Commitment Therapy (ACT) focus primarily on building the skills to alleviate suffering.

Both—skills for flourishing and skills for coping—are needed to achieve true well-being.

of reframing the negative, such as item 15: I think “The noise might be unpleasant, but it won’t drive me crazy,” and item 18: I think “There are things in life worse than tinnitus.”

Positive therapies for tinnitus?

Learning how to identify and modify negative thoughts related to tinnitus (sometimes called “cognitive restructuring”) is a core component of psychologically based therapies such as CBT. In the same way, learning how to identify and disengage with negative thoughts so that they have less emotional impact is a core component of ACT (sometimes called “mindfulness”).

Although these components are important for therapeutic benefit, positive psychology focuses primarily on components that build positive qualities, not those that repair negative qualities or impacts.6

Future Research Directions Positive psychology strives to rebalance mainstream psychology’s preoccupation with the negative, and it achieves this by focusing on what

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SPECIAL FEATURE

is required to build positive attributes, skills, and mindsets.

With this in mind, there seems to be an absence of scholarly work so far in applying positive psychology to tinnitus or hyperacusis. Exploratory studies of positive experiences report an assortment of concepts related to alleviating suffering and building well-being, but without attempting to clearly distinguish the two. Perhaps this is because the published work has been approached from the clinical practitioner’s perspective, where the ultimate goal is to reduce symptom severity, not to foster the ingredients for a good life.

I would argue that both are important and the last 20 years of research on positive psychology has convincingly shown that achieving the positive is not simply about eliminating the negative. Consistent with this is the observation that reporting one or more positive tinnitus experiences was not associated with lower symptom

severity compared to reporting no positive experiences at all.3 However, this phenomenon has not yet been explored fully in relation to tinnitus, and it has not been explored at all in relation to hyperacusis. In the box below, I set out several scientific and clinical research questions that remain unanswered.

Concluding Remarks Beukes and colleagues noted that many of the positive experiences reported by people with tinnitus were “cold comfort, meaning that they are small reassurances rather than growth experiences.”3 The second wave of positive psychology therefore presents an opportunity to teach people with tinnitus and hyperacusis how to grow from the negative and how to acknowledge and learn to be grateful for the positive. There is reason to be cautiously optimistic that greater discussion of positive experiences and a more explicit focus on strategies to

Unanswered Scientific Research Questions • What do the components of well-being (e.g., positive emotions, positive relationships, resilience) mean to people with tinnitus or hyperacusis?

• Do the components of well-being in these patient populations have the same meaning and salience compared to healthy people?

• What is a better predictor of self-reported symptom severity: subjective well-being, reporting of positive experiences, or reporting of negative experiences?

Unanswered Clinical Research Questions • Is it possible to motivate people with tinnitus or hyperacusis to think and feel more positively?

• Can therapies informed by positive psychology principles benefit people with tinnitus and hyperacusis?

• Can the known benefits of CBT (or ACT) be enhanced when combined with a positive psychology intervention?

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foster well-being would be of value in therapeutic counseling.

In the third and final article in this mini-series (to be published in the next issue), I delve into some promising, but so far unexplored, applications of positive psychology to tinnitus and hyperacusis and share practical tips that hopefully can help you live well with either condition.

Deborah Hall, PhD, is currently Professor of Positive Psychology and head of the Department of Psychology at Heriot-Watt University Malaysia.

Over the past 25 years, her research has spanned a range of topics on individual and societal well-being. She is recognized as a world leading expert on tinnitus, but past research projects also include exploring the relevance of positive soundscapes, developing a manualized psychological treatment to increase the knowledge base of audiologists in the U.K.’s National Health Service, and advocating to bring the public voice into clinical research. She can be reached at deborah.hall@hw.ac.uk 1 Seligman, M. E. P. (1999). The President’s Address (Annual Report). American Psychologist, 54, 559-562.

2 Manchaiah, V., Baguley, D. M., Pyykkö, I., Kentala, E., & Levo, H. (2015). Positive experiences associated with acquired hearing loss, Ménière’s disease, and tinnitus: A review. International Journal of Audiology, 54(1), 1-10.

3 Beukes, E. W., Manchaiah, V., Valien, T. E., Baguley, D. M., Allen, P. M., & Andersson, G. (2018). Positive experiences related to living with tinnitus: A crosssectional survey. Clinical Otolaryngology, 43(2), 489–495.

4 P. H. Wilson & J. L. Henry. (1998). Tinnitus Cognitions Questionnaire: Development and psychometric properties of a measure of dysfunctional cognitions associated with tinnitus. International Tinnitus Journal, 4(1), 23–30.

5 Handscomb, L. E., Hall, D. A., Shorter, G. W., & Hoare, D. J. (2017). Positive and negative thinking in tinnitus: Factor structure of the Tinnitus Cognitions Questionnaire. Ear and Hearing, 38(1), 126–132.

6 Pawelski, J. O. (2016). Defining the ‘positive’ in positive psychology: Part I. A descriptive analysis.

The Journal of Positive Psychology, 11(4), 339-356.

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 TINNITUS RESOURCES

Tinnitus Support Groups People with tinnitus at every stage in their journey, from the first few days to many years later, can benefit from membership in a support group. Every tinnitus support group operates differently; but they all share a passion for providing meaningful discussion and a caring

environment where one can be understood through shared experience. Below is a list of groups and meeting dates, current at time of print. Each support group referenced here is independently operated and led by volunteers who wish to provide education and support to the tinnitus community.

IN-PERSON MEETINGS The American Tinnitus Association (ATA) does not sponsor or endorse these activities and expressly disclaims any responsibility for the conduct of any independent support group or the information they may provide. ATA is not a healthcare provider and you should consult with a primary care physician or hearing healthcare professional for qualified medical advice on tinnitus and related disorders. *To allow for flexibility in planning, some groups do not schedule meetings far in advance. When we receive updates from support group leaders, we update meeting information in our online Events Calendar at www.ata.org. The information was provided to ATA staff at the time the magazine went to print; therefore, please confirm meeting details with the contact person prior to a meeting or reference our website at: https://www.ata.org/news/events.

This is a partial listing of support groups and scheduled meetings. A complete list can be found at https://www.ata.org/ managing-your-tinnitus/support-network/ support-group-listing. New groups continue to be added, so please check the website for updates periodically.

Due to ongoing Covid-19 concerns, it is critical to contact the support group leader directly to confirm meeting information and personal protection requirements.

Information provided on the ATA website is provided by support group leaders and is subject to change.

Colorado Mesa County Tinnitus Support Group Contact: Elaine Conlon T: 970–589–0305 E: conlonelaine@aol.com 3rd Wednesday of the month, 6:00 pm North Denver Tinnitus Support Group Contact: Melissa Golden T: 303–506–9389 E: mbaycon@hotmail.com Meeting dates & times TBD

Florida Clermont Tinnitus Support Group Contact: Dr. Laura Pratesi T: 352–989–5123 E: admin@citrushearing.com 2nd Monday of the month, 1:00 pm Sarasota Tinnitus Support Group Contact: Carmen Trotta, Tom Terrenzi T: 941–993–7616, 941–462–1311 E: sarasota.ata@gmail.com 3rd Friday of the month, 2:00–4:00 pm

Illinois Chicago Suburban Tinnitus Support Group Contact: Margie B. E: maggie318@yahoo.com Meeting dates & times TBD

Massachusetts Boston Tinnitus Support Group Contact: Kevin Plovanich E: JKPMA@aol.com

Michigan Grand Rapids Individual Support Contact: Robert Ellis T: 616–949–4911 E: prohitter@att.net Holland Tinnitus Support Group Contact: Stelios Dokianakis Website: https://holaud.com/contact/ T: 616–392–2222 E: info@holaud.com Contact for meeting information

New York Long Island Tinnitus Group Contact: Anthony Mennella T: 516–379–2534 E: aem830@verizon.net Currently not meeting. Contact group leader by email for support.

If you’re interested in forming a group, please contact Joy Onozuka at tinnitus@ata.org.

If there isn’t a group in your area, ATA has an extensive network of volunteers who provide email and telephone support and educational information.

To connect with a volunteer in your time zone, see: https://www.ata.org/ managing-your-tinnitus/support-network/ telephoneemail-support-listing.

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www.ATA.org

TINNITUS RESOURCES 

VIRTUAL MEETINGS Please email/call the point-of-contact person listed for information on upcoming meetings.

Arizona Tucson Tinnitus Support Group Contact: Trudy Jacobson E: trudyj@cox.net 4th Saturday of the month, 1:00 pm

California Los Angeles/Orange County Tinnitus Support Group Contact: Barry Goldberg E: bargold06@yahoo.com 3rd Saturday of month, 10:00 am Palo Alto Tinnitus Support Group at Avenidas Contact: Ken Adler E: karmtac@aol.com 3rd Thursday of the month, 5:30–7:30 pm Sacramento Area Tinnitus Support Group Contact: Pat Clark E: sactinnitus@gmail.com 2nd Wednesday of the month, 6:30–8:00 pm San Francisco Tinnitus Support/ Education Group Contact: Tracy Peck Holcomb T: 800–865–3142 E: tracy@treblehealth.com 3rd Thursday of the month, 3:00 pm Hearing Loss & Tinnitus Support Group Contact: Mimi Salamat E: dr.mimi@yourhearingdoc.com 1st Thursday of the month, 7:00–8:30 pm via Meetup Meetup Link: https://meetu.ps/e/L5Td7/J3hcb/i NEW

NEW Musicians With Tinnitus Support Group Contact: Michelle Neidleman Kennedy E: Michelle@TrebleHealth.com 2nd Tuesday of the month, 10:00 am

Colorado Denver Tinnitus Support Group Contact: Rich Marr T: 303–875–5762 E: richard.marr@ccc.edu 2nd Monday of the month, 7:00–8:30 pm

Florida Tampa Tinnitus Support Contact: Joel DeAngelis T: 813–420–0160 E: joel.deangelis70@gmail.com 3rd Monday of the month, 7:00 pm

www.ATA.org

Georgia The ENT Institute Tinnitus Support Group Contact: Sonia Hamidi, AuD, CH–TM T: 678–347–2123 E: shamidi@nsainstitute.com 3rd Thursday of the month, 6:00 pm

Maryland University of Maryland Tinnitus and Hyperacusis Support Group Contact: Christina Shields, AuD T: 301–405–5562 E: shields3@umd.edu Meets quarterly, dates and times TBD

Missouri St. Louis Tinnitus Support Group Contact: Tim Busche T: 636–734–4936 E: tbusche@stltinnitus.org 1st Wednesday of even months, 7:00–9:00 pm

New Jersey South Jersey Tinnitus Support Group Meeting virtually via Zoom Contact: Beth Savitch, Erin Lustik E: tsg@advancedent.com 1st Thursday of the month, 7:00–8:30 pm

New York Bronx Tinnitus Support Group Contact: Dr. S. Karie Nabinet T: 917–797–9065 E: kkwn12u@aol.com 1st Thursday of the month, 6:30 pm

Oregon VA Portland Health Care System Tinnitus Education Group Contact: Bryan Shaw T: 503–220–8262, ext. 55568 E: Bryan.Shaw2@va.gov Meeting dates and times TBD

Pennsylvania Lehigh Valley Tinnitus Support Group Contact: Luke Ciaccio, PhD T: 610–776–3117 E: lciaccio@gsrh.org 2nd Tuesday of month, 5:30–6:30 pm

Texas Dallas/Ft. Worth Tinnitus Support Group Contact: John Ogrizovich E: dfwtsg@yahoo.com Meets every 4–6 weeks, Saturday, 10:00 am

Houston Tinnitus Support Group Contact: Vinaya Manchaiah E: houstontinnitus@gmail.com Meeting dates and times TBD

Virginia National Capital Region Tinnitus Support Group Contacts: Elaine Wolfson, David Treworgy E: erwolfson@comcast.net E: david_treworgy@yahoo.com Meets monthly

Washington Seattle Tinnitus Support Group Contact: Keith Field T: 206–783–7105 E: Keith_r_field@outlook.com Last Wednesday of month, 6:30–8:00 pm

Wisconsin Madison Tinnitus Support Group Contact: Deb Holmen T: 608–219–0277 E: dholmenihearu@gmail.com 4th Wednesday of the month, 6:30–7:30 pm

HYBRID MEETINGS California San Diego Tinnitus and Hyperacusis Support Group Contacts: Michael J. Fischer, Loretta Marsh, David Phaneuf, Tom Sutton E: michaeljohnfischer@hotmail.com E: lorettamarsh@hotmail.com E: djphaneuf@yahoo.com E: tomsutton63@gmail.com 1st Tuesday of the month, 6–7:30 pm

Texas Austin & San Antonio Tinnitus Support Group Contact: Matthew Randal T: 512–660–7276 E: atasg.satx@gmail.com 1st & 2nd Saturday of the month, 11:00 am

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HEALTHCARE PROVIDERS

Spotlight on Patient Providers Professional Members Listing current as June 28, 2022

When making an appointment, please mention that you learned of the provider from the ATA, thereby ensuring that providers understand the importance of being a part of the ATA’s tinnitus patient provider network.

COLOR KEY Purple: Audiology Green: Medical practitioner Blue: Hearing aid dispenser Orange: Therapist Pink: Complementary/Alternative Medicine practitioner Navy: Other

UNITED STATES Alabama Susan Sheehy, AuD Alabama Hearing Associates Madison, AL

Alaska Emily McMahan, AuD, CH–TM Alaska Hearing & Tinnitus Center Anchorage, AK

Arizona Lynn Callaway, BC–HIS Affordable Hearing Solutions Green Valley, AZ Judy Huch, AuD Oro Valley Audiology, Inc. Oro Valley, AZ Peter Vernezze, MSW, PhD The Tinnitus Coach Tucson, AZ Rachel Zovko, AuD, CH–TM Sound Relief Hearing Center Scottsdale, AZ

Arkansas Kelley Linton, AuD, CH–TM Center for Hearing, Ltd. Fort Smith, AR

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Michael Osterbur, PT Natural State Health Center Little Rock, AR

California Kasra Abolhosseini, AuD Tustin Hearing Center Tustin, CA Melissa Alexander, AuD Alexander Audiology, Inc. Santa Monica, CA John Barrett, Lac The Acupuncture Wellness Center, Inc. Los Angeles, CA Joe Bartlett, BC–HIS Bartlett’s Hearing Aid Center Chico, CA Randall Bartlett, MA Tinnitus & Audiology Center of Southern California, Inc. Santa Clarita, CA Maryellen Brisson, AuD Hermosa Beach, CA Shahrzad Cohen, AuD, CH–TM Hearing Loss Solutions Sherman Oaks, CA David DeKriek, AuD Fidelity Hearing Center Cerritos, CA Gregory Frazer, AuD Pacific Hearing & Balance Center, Inc. Los Angeles, CA Jennifer J. Gans, PsyD Mindful Tinnitus Relief San Francisco, CA Amit Gosalia, AuD West Valley Hearing Center Woodland Hills, CA Tracy Peck Holcomb, AuD Treble Health San Francisco, CA Beverly Lew, AuD Sound Advice Burbank, CA

Peter J. Marincovich, PhD Audiology Associates Santa Rosa, CA Sara Mattson, AuD Rancho Santa Fe Audiology Rancho Santa Fe, CA Kirsten McWilliams, AuD, CH–TM The Hearing Solution Sacramento, CA Amy Nelson, AuD, CH–TM Kaiser Permanente Santa Clara, CA Janine Newkirk, AuD, CH–TM Stanford Health Care Menlo Park, CA Marni Novick, AuD, CH–TM Silicon Valley Hearing, Inc Los Gatos, CA Angela O’Boyle, AuD Hearing Associates Inc. Northridge, CA Bruce Piner, AuD Hearing and Balance Center Encino, CA Ashley Potter, AuD Humboldt Audiology Eureka, CA Brook Raguskus, AuD, CH–TM Pacific Hearing Service Los Altos, CA Jane Rosner, AuD West Valley Hearing Center Woodland Hills, CA Jessica D. Russell, MA The Hypnotherapy Centers Los Angeles, CA Mimi Salamat, PhD Dr. Mimi’s Audiology Clinic Walnut Creek, CA Christopher Sumer, NBC–HIS Coastal Hearing Aid Center Encinitas, CA Ben Thompson, AuD Treble Health Berkeley, CA

www.ATA.org

HEALTHCARE PROVIDERS

Brian Worden, MD Kaiser Permanente Woodland Hills, CA

Colorado Morgan Ashby, AuD, CH–TM Sound Relief Hearing Center Westminster, CO Lindsay Collins, AuD, CH–TM Sound Relief Hearing Center Centennial, CO Terry Cummings, AuD, CH–TM Columbine Audiology and Hearing Aid Center Sterling, CO Julie Eschenbrenner, AuD Flatirons Audiology, Inc. Lafayette, CO Kaela Fasman, AuD, CH–TM Sound Relief Hearing Center Golden, CO Emily Hensarling, AuD, CH–TM Kaiser Permanente Lone Tree, CO Krisztina Johnson, AuD, CH–TM Hearing Associates New Castle, CO Tony Kovacs, AuD, CH–TM Sound Relief Hearing Center Fort Collins, CO Kevin McConnell, HIS Ideal Hearing Solutions LLC Lakewood, CO Abigail McMahon, AuD, CH–TM Sound Relief Hearing Center Fort Collins, CO Leah Mitchell, AuD, CH–TM Sound Relief Hearing Center Westminster, CO Drew Price, AuD, CH–TM Sound Relief Hearing Center Denver, CO Julie Prutsman, AuD, CH–TM Sound Relief Hearing Center Highlands Ranch, CO Jackie Smith, AuD, CH–TM Sound Relief Hearing Center Highlands Ranch, CO Mandi Solat, AuD, CH–TM Audiology Services & Hearing Aid Center Lakewood, CO Robert M. Traynor, EdD, CH–TM Fort Collins, CO

www.ATA.org

Connecticut Natan Bauman, EdD Auditory and Vestibular Institute of New England Hamden, CT

District of Columbia Patricia T. Demont, PhD Washington, DC

Delaware Megan E. Boehler, AuD Bayside Audiology & Hearing Aids Lewes, DE

Florida Indira Alvarez, AuD Palm Coast Hearing Center Palm Coast, FL Kelly Breese, AuD, CH–TM Murphy Hearing Aids of Sarasota Sarasota, FL Anne Carter, PhD, CH–TM Pasadena Hearing Care South Pasadena, FL Maura Chippendale, AuD, CH–TM Chippendale Audiology Cape Coral, FL Melissa Kipp Clark, AuD Suncoast Hearing Services Plus Bradenton, FL Noel Crosby, AuD Advanced Hearing Solutions Englewood, FL Ali Danesh, PhD Labyrinth Audiology Boca Raton, FL Kelly J. Dyson, AuD Suncoast Audiology, LLC Largo, FL Melodi Fehl, MS ENT and Allergy Associates of Florida Boca Raton, FL Lisa Gascay, AuD, CH–TM Rainbow River Hearing & Balance Inc. Dunnellon, FL Megan Labbe, AuD, CH–TM St. Luke’s Cataract and Laser Institute Tampa, FL Todd Landsberg, AuD Foot Prints Hearing Center Miami Beach, FL Coos Bay, OR

Janice T. Powis, AuD Mind Over Tinnitus St. Augustine, FL Karthikeyan Sai, MD Palm Beach Kidney & Hypertension Wellington, FL Cindy Ann Simon, AuD South Miami Audiology Consultants South Miami, FL Mindy Stejskal, MCD The Hearing Center Pensacola, FL Susan E. Terry, AuD Broadwater Hearing Care St. Petersburg, FL Liz White, AuD Harbor City Hearing Solutions Melbourne, FL Kayla Wilkins, AuD Aspire Hearing and Balance Lakeland, FL

Georgia Laura Barber, AuD, CH–TM Augusta University Health–Audiology Associates Augusta, GA Christopher V. Campellone, HIS GoToHearing Gainesville, GA Kerry Cohen, AuD University of Georgia Speech and Hearing Clinic Athens, GA Sonia Hamidi, AuD, CH–TM ENT Institute Buford, GA Jan Henriquez, AuD At Home Hearing Woodstock, GA Brian K. Jones, MEd Greater Atlanta Hearing Inc. Cumming, GA Karla McKenzie, MCD My Hearing Aid Place Richmond Hill, GA Liz Ramos, AuD, CH–TM ENT of Georgia/Advanced Hearing Atlanta, GA Georgeanne Thomas, AuD Hearing & Balance Clinic Watkinsville, GA Nikki Weaver, AuD Fayette Hearing Clinic and Coweta Hearing Clinic Peachtree City, GA

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HEALTHCARE PROVIDERS

Melissa Wikoff, AuD, CH–TM Peachtree Hearing Marietta, GA

Hawaii Amanda Seeley, AuD Advanced Pacific ENT Wailuku, HI

Idaho Christine Pickup, AuD Mt. Harrison Audiology & Hearing Aids, LLC Rupert, ID Tosha Strickland, AuD Strickland Ear Clinic Meridian, ID

Illinois Steve Bonzak, MS Health Traditions Chicago, IL Mary C. Chisholm, AuD Northwest Speech and Hearing Ltd. Arlington Heights, IL Nancy Congdon, AuD, CH–TM The Hearing Care Clinic Downers Grove, IL Phillip Elbaum, LCSW Stritch School of Medicine Loyola University, Chicago Deerfield, IL Dru A. Geraghty, MS Audiologic Services Glen Ellyn, IL Lori A. Halvorson, AuD, CH–TM Lake Forest Hearing Professionals Lake Forest, IL Jaclyn Jansen, AuD Sarah Bush Lincoln Effingham, IL Jill Meltzer, AuD, CH–TM Jill Meltzer, AuD Consulting PLLC Northbrook, IL Janaan S. Moore, AuD Michigan Avenue Hearing Health Chicago, IL James H. Peck, HIS Life Hearing Health Centers Rockford, IL Jeanne Perkins, AuD Audiologic Services Glen Ellyn, IL

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Daria Popowych, AuD North Side Audiology Group, Inc. Chicago, IL Susan Schiff, LCSW Oak Park, IL Alyssa Seeman, AuD Illinois State University Normal, IL

Indiana Curt Esterline, HIS Concierge Hearing Healthcare New Haven, IN Erica Person, AuD, CH–TM Flex Audiology Lawrenceburg, IN Elizabeth Zweigart, AuD Midwest Ear Nose & Throat Surgery Evansville, IN

Iowa Diana Kain, AuD Heartland Hearing Center Hiawatha, IA Beki Kellogg, AuD Hope Hearing & Tinnitus Center Hiawatha, IA Jill Nesham, AuD Professional Hearing Solutions by Dr. Jill Cedar Rapids, IA Heather Thatcher, HIS Hope Hearing & Tinnitus Center Hiawatha, IA

Kansas Bryne Gonzales, AuD NuSound Hearing & Tinnitus Center Topeka, KS James Mangimelli, AuD Atchison, KS

Kentucky Vanessa L. Ewert, AuD Bluegrass Hearing Clinic Lexington, KY

Louisiana Leanne Battler, AuD United States Army Fort Polk, LA Catherine C. Lo, AuD The Hearing Clinic Thibodaux, LA Mary Miller, PhD Premier Hearing and Balance Hammond, LA Ram Nileshwar, AuD The Hearing Center of Lake Charles Lake Charles, LA Elena Treadway, AuD Noel ENT Hearing Center Abbeville, LA

Maryland Toni A. Brightwell, AuD Hearing Associates Inc. Havre de Grace, MD Chelsea Campbell, AuD Allegany Hearing and Balance Lavale, MD Chelsea Carter, AuD University of Maryland Medical Center Baltimore, MD Katelyn M. Leitner, AuD, CH–TM Hearing Assessment Center Nottingham, MD Candice Ortiz–Hawkins, AuD Capital Institute of Hearing & Balance Silver Spring, MD Yael Schonfeld, AuD Chesapeake Ear, Nose & Throat Owings Mills, MD LaGuinn Sherlock, AuD, CH–TM Walter Reed National Military Medical Center Bethesda, MA Christina Shields, AuD University of Maryland College Park College Park, MD

Massachusetts

Ann Rhoten, AuD Kentucky Audiology & Tinnitus Services Lexington, KY

Dierdre Anderson, AuD Audiology Network Services Salisbury, MA

Kari A. Wickstrom, AuD Bluegrass Hearing Clinic Nicholasville, KY

Eugene Antonell, BC–HIS Hear Better Now Tinnitus & Hearing Center N. Dartmouth, MA

www.ATA.org

HEALTHCARE PROVIDERS

Nataliya Ayzenberg, PhD, AuD, CH–TM Moon Hearing Services, LLC Woburn, MA

MaryRose Hecksel, AuD Audiology & Hearing Aid Center Lansing, MI

Judith Bergeron, BC–HIS, CDP Beauport Hearing Care Gloucester, MA

Tiffany Inman, AuD Inman Audiology Troy, MI

Joni Skinner Bullough, AuD Hampshire Hearing & Speech Northampton, MA

Angela Lederman, MS Hear Now Audiology & Tinnitus Center Clinton Township, MI

Collin Campbell, Lac Campbell Acupuncture and Herbal Medicine Clinic South Dennis, MA Theresa Cullen, AuD, CH–TM Cape Cod Hearing Center Hyannis, MA Nancy Duncan, AuD, CH–TM Duncan Hearing Healthcare Fall River, MA Kenneth Grundfast, MD Boston University School of Medicine/ Massachusetts Eye and Ear Boston, MA

Jacklyn Miller, AuD Advanced Audiology DeWitt, MI Shannon Radgens, DO Red Cedar Ear Nose & Throat & Audiology Owosso, MI Michelle Rankin, AuD Rankin Audiology and Hearing, LLC Chelsea, MI Benjamin Wightman, AuD Sound Advice Audiology Livonia, MI

Minnesota

Peter Harakas, PhD CBT Associates, LLC Lexington, MA

Jennifer Anfinson, AuD Treble Health Plymouth, MN

Dana Mario, AuD Mario Hearing & Tinnitus Clinics Mansfield, MA

John Coverstone, AuD, CH–TM Audiology Ear Care New Brighton, MN

Robert Mario, BC–HIS, PhD Mario Hearing & Tinnitus Clinics Cambridge, MA

Sara Downs, AuD Hearing Wellness Center Duluth, MN

Shannon O’Rourke, AuD Cape Cod Hearing Center Hyannis, MA

John Ehlen Hear Central Victoria, MN

Karen L. Wilber, AuD, CH–TM Boston Children’s Hospital Boston, MA

Jason Leyendecker, AuD Audiology Concepts Edina, MN

Michigan Natalie Crossland, AuD, CH–TM Holland Doctors of Audiology Holland, MI Felix Cruz, BC–HIS Cruz Hearing Aid Service Farmington Hills, MI Stelios Dokianakis, AuD, CH–TM Holland Doctors of Audiology Holland, MI

Laura Morrison, AuD, CH–TM White Bear Lake, MN Gayla Poling, PhD Mayo Clinic Rochester, MN Jennifer Reynolds, AuD Reynolds Audiology & Tinnitus Center Woodbury, MN Jerry Zhou, PhD Hearing of America, LLC Oakdale, MN

Missouri Laura Flowers, AuD Hearing and Balance Specialists of Kansas City Lee’s Summit, MO Jay Piccirillo, MD Washington University School of Medicine Saint Louis, MO

Nevada Robyn Lofton, BC–HIS Hearing Associates of Las Vegas Las Vegas, NV

New Jersey Granville Y. Brady Jr., AuD East Brunswick, NJ Jade Igbokwe, AuD, CH–TM NTI Audiology Jersey City, NJ William J. McDonnell, VSO Dept. of Veterans Affairs Mount Laurel, NJ Nicole Piasentini, AuD New Jersey Hearing Health Center Brick, NJ Marion Rollings, PhD Holistic Health Counseling Center LLC Hillsborough, NJ Beth Savitch, MA Advanced ENT/Hear MD Voorhees, NJ Donna Szabo, AuD Innovative Hearing Solutions Westwood, NJ

New Mexico Susan Allshouse, AuD Wendy Gallegos Audiology Corrales, NM Jeffrey W. Wise, AuD, CH–TM Expert Hearing Care Las Cruces, NM Catherine A. Worth, MS Capital Hearing Care Albuquerque, NM

New York Nicole Ball, AuD Hearing Evaluation Services of Buffalo, Inc. Tonawanda, NY

Allie Heckman, AuD, CH–TM Michigan Medicine–University of Michigan Ann Arbor, MI

Dawn L. Bowerman, MS dB Hearing Center Williamsville, NY

www.ATA.org

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HEALTHCARE PROVIDERS

Lois Cohen, LCSW, ACSW, BCD Tinnitus Counseling Northport, NY

Alicia L. Cristobal, AuD Hearing Health Care Services, PLLC Durham, NC

Heather Malyuk, AuD Soundcheck Audiology Cuyahoga Falls, OH

Bruce Hubbard, PhD CBT for Tinnitus, LLC New York, NY

Lisa Fox–Thomas, PhD UNCG Speech and Hearing Center Greensboro, NC

Heather Maze–Smith, AuD Maze Hearing, LLC Bellefontaine, OH

Harriet Jacobster, AuD Lyric Audiology New Windsor, NY

Goutham Gosu, AuD Hearing Solution Center Charlotte, NC

Tracey Lynch, AuD Island Better Hearing Inc. Melville, NY

Hannah Heet, AuD, CH–TM Duke Otolaryngology of Raleigh Raleigh, NC

Eric Mounts, HIS Modern Hearing Solutions/Choice Hearing Center Canton, OH

Amy Sapodin, AuD Advanced Hearing Center Albertson, NY

Julia Hubbard–Rossi, AuD Carolina Hearing and Tinnitus, PC Mooresville, NC

Leigh A. Sauerbier, AuD, CH–TM The Advanced Hearing Center Brooklyn, NY

Patricia Johnson, AuD, CH–TM UNC School of Medicine Chapel Hill, NC

Jeffrey M. Shannon, AuD Hudson Valley Audiology Pomona, NY

Nancy McKenna, AuD, PhD University of North Carolina Chapel Hill Chapel Hill, NC

Alyssa Smyczynski, AuD Hearing Evaluation Services of Buffalo, Inc. Orchard Park, NY

Melissa Palmer, AuD High Point Audiological–Clayton Clayton, NC

Amanda Snell, AuD Finger Lakes Audiology, PLLC Horseheads, NY

Stan Phillips, MD South Lake Hearing and Tinnitus Center Huntersville, NC

Randall Solomon, MD Long Island Mental Health Port Jeff Station, NY

Ivy Saul, AuD Audiology & Hearing Services of Charlotte Charlotte, NC

Anna Forsline, AuD VA Portland Healthcare System Portland, OR

Jennifer Sutton, AuD Hearing Evaluation Services of Buffalo, Inc. Williamsville, NY

Michael B. Slater, AuD South Lake Hearing and Tinnitus Center Huntersville, NC

Kristen Furseth, AuD, CH–TM Willamette ENT Salem, OR

Lori Trentacoste, AuD Island Better Hearing Inc. Melville, NY

Emilee V. Tucker, AuD, CH–TM Carolina Ear, Nose & Throat—Sinus and Allergy Center, PA Hickory, NC

Bryan J. Greenaway, AuD, CH–TM Pacific University Hillsboro, OR

Erin M. Walborn–Sterantino, AuD Audiologic Solutions Rensselaer, NY Carolyn Yates, AuD, CH–TM Hearing Evaluation Services of Buffalo, Inc. Amherst, NY

North Carolina Jennifer Auer, AuD Audiology Attention & Tinnitus Care, PLLC Concord, NC Susan Bergquist, MS Heritage Audiology Wake Forest, NC Jennifer Clarke, AuD Audiology of Southpoint Durham, NC

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North Dakota Mackensie Brandt, AuD Altru Professional Center Grand Forks, ND

Ohio Samantha Bayless, AuD, CH–TM The Hill Hear Better Clinic Cincinnati, OH Sarah E. Curtis, AuD Sounds of Life Hearing Center, LLC Concord Township, OH Cathy Kooser, MSW, LISW Hillcrest Hearing & Balance Center Centerville, OH

Richard Reikowski, AuD Family Hearing & Balance Center Akron, OH Eryn Staats, AuD Memorial ENT Marysville, OH Babette Verbsky, PhD, CH–TM Hearing Connections Audiology Lebanon, OH Gail Whitelaw, PhD, CH–TM The OSU Speech–Language–Hearing Clinic Columbus, OH Kyle Woods, MA, CH–TM Modern Hearing Solutions/Choice Hearing Center Canton, OH

Oregon

James Henry, PhD National Center for Rehabilitative Auditory Research (NCRAR) Portland, OR Erika Shakespeare, MSc Audiology & Hearing Aid Services La Grande, OR Sandi L.B. Ybarra, AuD Hearing Associates Eugene, OR

Pennsylvania Krista Blasetti, AuD York ENT Associates York, PA

www.ATA.org

HEALTHCARE PROVIDERS

Gail Brenner, AuD Tinnitus & Sound Sensitivity Treatment Center of Philadelphia, PC Bala Cynwyd, PA

Courtney C. Guthrie, AuD 4 Bridges Audiology Chattanooga, TN

Mark Hedrick, AuD Texas Tinnitus and Hearing Flint, TX

Mindy Brudereck, AuD, CH–TM Berks Hearing Professionals Birdsboro, PA

Andrea Plotkowski, AuD Ear, Nose and Throat Consultants of East Tennessee Knoxville, TN

Rachel Higginbotham, AuD Estes Audiology Hearing Centers Boerne, TX

Linda Dallas, MEd Allentown Ear, Nose and Throat Allentown, PA

Paul Shea, MD Shea Ear Clinic Memphis, TN

Amy Greer, AuD, CH–TM Lemme Audiology Associates Ebensburg, PA Jennifer Isayev, AuD Audiometrics, Inc. Bryn Mawr, PA Jeannie Karlovitz, AuD Advanced Hearing Solutions Exton, PA Anthony Napoletano, HIS Lansdowne Hearing Lansdowne, PA

Rhode Island Holly Puleo, AuD Gateway Hearing Solutions Warwick, RI

South Carolina Todd Gibson, AuD Lake Murray Hearing Lexington, SC Alexandra Tarvin, AuD Elevate Audiology Hearing and Tinnitus Center Easley, SC Jennifer Waddell, HIS Sound Hearing Care Simpsonville, SC Jason P. Wigand, AuD LifeAloud, LLC Lexington, SC

Texas S. Diane Allen, PhD The Grove Counseling & Wellness Center Dallas, TX Amanda Ammerman, PA–C Austin Regional Clinic Austin, TX Theodore Benke, MD Benke Ear, Nose, & Throat Clinic Cleburne, TX Arica Black, AuD The Hearing Doctor Lubbock, TX Lacey Brooks, AuD North Houston Hearing Spring, TX Bethany Brum, AuD, CH–TM UT Southwestern Medical Center Dallas, TX E. Suzanne Carter, LPC San Antonio, TX Heather Dean, AuD Burleson Audiology Clinic Burleson, TX Shannon Frugia, AuD, CH–TM Southeast Texas Ear Nose & Throat Beaumont, TX Mary Sue Harrison, AuD Today’s Hearing Katy, TX

Carla S. Hoffman, HIS Hoffman Hearing Solutions Corpus Christi, TX Margaret Hutchison, PhD, CH–TM Austin Hearing Services Austin, TX Susan Hyman, AuD Hyman Hearing Beaumont, TX Kristen Keener, AuD IlluminEar Tinnitus & Audiology Center Austin, TX Christina Lobarinas, AuD UT Southwestern Medical Center Dallas, TX Celia Miranda, AuD, CH–TM Hear In Texas New Braunfels, TX Rene Pedroza, AuD, CH–TM United States Department of Defense El Paso, TX Elly Pourasef, AuD Memorial Hearing Houston, TX Lydia Ramanovich, AuD, CH–TM Dallas Ear Institute Frisco, TX Christie Spencer, AuD Fort Bend Hearing Sugar Land, TX Crystal Wiggins, AuD, CH–TM Memorial Hearing Houston, TX

South Dakota Melissa E. Baker, MA Baker Audiology and Hearing Aids Sioux Falls, SD

Tennessee Tiffany Ahlberg, AuD Ahlberg Audiology & Hearing Aid Services Cleveland, TN Marc Fagelson, PhD East Tennessee State University Johnson City, TN

www.ATA.org

Please note that the American Tinnitus Association does not verify providers’ certifications and expertise in tinnitus treatment. The list is meant expressly for informational purposes and should not be construed as the ATA’s endorsement of the providers listed. The ATA strongly advises anyone using the list to check practitioners’ websites and tinnitus services before scheduling appointments. Please note that the list includes hearing aid dispensers because hearing aids can be helpful to some people in the management of their tinnitus.

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HEALTHCARE PROVIDERS

Utah

Wisconsin

Layne Garrett, AuD Timpanogos Hearing American Fork, UT Jessica Lui Nelson, BC–HIS Timpanogos Hearing Spanish Fork, UT Lindsey Tubaugh, AuD Little Heroes Pediatric Hearing Clinic Layton, UT

Vermont Stephanie Hollop, AuD, CH–TM Univ. of Vermont–E.M. Luse Center Burlington, VT

Virginia Kimberly Abeyta, AuD Hearing Resource Center Fredericksburg, VA Ana Anzola, AuD Ascent Hearing McLean, VA Theresa H. Bartlett, AuD Virginia Hearing Consultants Virginia Beach, VA Ann DePaolo, AuD The Audiology Offices, LLC Kilmarnock, VA Julie Farrar–Hersch, PhD Augusta Audiology Associates, P.C. Fishersville, VA Kristin Koch, AuD Evolution Hearing Charlottesville, VA Fred W. Lindsay, DO Hampton Roads ENT and Allergy Hampton, VA

Washington Troy J. Bacon, CHt New Being Hypnosis Seattle, WA Anne Harvey, AuD University of Washington Medical Center–Montlake Seattle, WA Thomas A. Littman, PhD, CH–TM Factoria Hearing Center Bellevue, WA Dustin Spillman, AuD, CH–TM Audiologists Northwest Bremerton, WA

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Jon Douglas, AuD, CH–TM University of Wisconsin Tinnitus and Hyperacusis Program Madison, WI Hugo Guerrero, AuD, CH–TM Mayo Clinic Health System Onalaska, WI Veronica Heide, AuD, CH–TM Audible Difference, LLC Madison, WI Dan Malcore The Hyperacusis Network Green Bay, WI Melinda O’Meara, HIS Defatta ENT Altoona, WI Mandy Rutta, AuD Gundersen Health System La Crosse, WI Samantha Sikorski, HIS, ACA Sikorski Hearing Aid Center, Inc. Spooner, WI

Wyoming Brendan Fitzsimmons, MD St. John’s–Lander Lander, WY

U.S. TERRITORIES Puerto Rico Isamar Gonzalez–Feliciano, AuD Centro Audiológico e Interdisciplinario, Isamar González, Inc. Arecibo, PR Soami Santiago de Snyder, PhD Universidad de Puerto Rico Medical Sciences Campus Gurabo, PR

INTERNATIONAL Argentina Susana A. Dominguez Audiologist Buenos Aires

Australia Lynne Blackford, BSc MQ Health Speech and Hearing Clinic North Epping, NSW

Canada Ronald Choquette, AuD, CH–TM Montreal University Audiology Clinic Montreal, QC Sabrina DeToma, AuD Salus Hearing Centre Vaughan, ON Patrick DeWarle, AuD, CH–TM Winnipeg Hearing Centres Winnipeg, MB Heidi Eaton, AuD Argus Audiology Moncton, NB Kimberly Eskritt, AuD Lambton Audiology Associates Sarnia, ON Sylvie Hébert, PhD Tinnitus and Hyperacusis Research Laboratory Montreal, QC Deborah R. Lain, MSc Hope For Tinnitus Calgary, AB Carol A. Lau, HIS Sound idEARS Inc. Vancouver, BC Larena Lewchuk, MClSc Audiology Clinic of Northern Alberta Edmonton, AB Lucy Xie, HIS Bow River Hearing Calgary, AB

Malaysia Wan Syafira Ishak, PhD, CH–TM Universiti Kebangsaan Malaysia, Malaysia Kuala Lumpur, KL

Serbia Milena Tomanic, MD, PhD Faculty of Medicine, University of Belgrade Novi Beograd

United Kingdom Lisa Caldwell The Hearing Coach Glossop, UK Alan Hopkirk The Invisible Hearing Clinic Paisley, UK

Paul B. Davis, PhD, MAuDSA Tinnitus TeleCare Suffolk Park, NSW www.ATA.org

TINNITUSTODAY Editorial Calendar Tinnitus Today magazine is a print and electronic media magazine published in April, August, and December, and circulated to 25,000+ ATA contributors, donors, patients, supporters, researchers, and healthcare professionals.

The magazine editorial team empowers readers with information, including up-to-date medical and research news, feature articles on urgent tinnitus issues, questions and answers, self-help suggestions, and letters to the editor from others with tinnitus. Strong service journalism, compelling storytelling, first-person narrative, and profiles are presented in an inviting format to encourage readers to reflect, engage, and better understand a chronic condition that affects millions.

Editorial Copy Due

Photos Due

Ad Close

Digital Launch

Issue Mailed

Annual Research Issue

9/15

10/1

10/1

12/1

December

Spring–Apr 2023

Community Engagement

1/15

2/1

2/1

4/1

April

Summer–Aug 2023

Tinnitus and the Brain

4/15

5/1

5/1

8/1

August

Issue

Theme

Winter–Dec 2022

Editorial Calendar is subject to change.

To advertise, contact: tinnitus@ata.org

MISSION AND CORE PURPOSE The mission and core purpose of the ATA are to promote relief, help prevent, and find cures for tinnitus evidenced by its core values of compassion, credibility, and responsibility.

CORE VALUES AND GUIDING PRINCIPLES Compassion: Evidenced in a spirit of hope reflected in the commitment to finding a cure, preventing the condition, and supporting those affected by the condition.

Credibility: Evidenced in accurate information from reliable sources, transparency in decisionmaking, and an earned reputation for trustworthiness.

Responsibility: Evidenced in patient-centered advocacy by a collaborative community of forward thinking leaders accountable to its mission and members. www.ATA.org

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Open Access ATA’s Conversations in Tinnitus, with John A. Coverstone, AuD, and Dean Flyger, AuD ATA PODCASTS ARE FREE AND OPEN ACCESS

Tune In to Stay Abreast of Tinnitus Research and News The American Tinnitus Association’s podcasts are available 24/7 to help you stay abreast of tinnitus research and other tinnitus topics. Just like listening to music on your smartphone or computer, you can tune in to Conversations in Tinnitus podcasts, while you work out, take a walk, relax at home, or commute to work. To access and learn more about this unique series, visit our website at www.ata.org. To enhance listening comprehension and accommodate those with noise sensitivity, transcripts are available with each podcast.

These are only a few of the episodes from our podcast library.

Episode 16: Considering the Psychophysiological Elements of Tinnitus SUBJECT MATTER EXPERT: Christopher Spankovich, PhD, MPH TOPIC: Dr. Christopher Spankovich discusses how tinnitus interventions should address both the psychological and physiological impact of tinnitus on patients. He explores how nutrition, emotional health, and physical health all play a role in mitigating the negative impact of tinnitus. He

also discusses the importance of helping patients understand the power of sound to elicit positive or negative emotions, aside from the tinnitus sound, in order to facilitate habituation. Noting that not all patients believe or accept the psychological component of tinnitus, Dr. Spankovich encourages providers to assess what best fits the needs of individual patients, taking into consideration their specific challenges, what the patient believes, and what he/she is likely to respond to, rather than focusing on a one-size-fits-all approach.

Episode 13: Understanding Preferences for Loud Music SUBJECT MATTER EXPERT: Elizabeth Beach, PhD TOPIC: Dr. Elizabeth Beach discusses large-scale research that reveals why clubs, bar, and music venues are playing music at higher volumes than what most people prefer. And while it might seem easy to raise awareness that results in quieter recreational music venues, Beach says it’s complicated, so safe listening initiatives require support at various levels to achieve change. As head of the Behavioral Sciences Department at the National Acoustics Laboratory in Australia, she studies recreational noise in the music and entertainment industry, strategies for encouraging safe listening for staff and patrons, and how to motivate young adults to protect their hearing.

The ATA has earned the 2022 Platinum Seal of Transparency from Candid (formerly GuideStar and Foundation Center), illustrating the ATA’s commitment to sharing our strategy, metrics, and achievements with members and donors.

To subscribe to the print or digital issue of Tinnitus Today, which is published three times a year, visit www.ata.org or email memberservices@ata.org