1. A New Approach to Tinnitus - Mindfulness-meditation Dr Veronica Kennedy Irish Tinnitus Association 27-11-08

2. Acknowledgments Dr Laurence McKenna/Richard Irwin Mike Sadlier

3. Not a cure Not a treatment specifically for tinnitus But A way to improve our ability to coping with tinnitus

4. Mindfulness-meditation Concept 1979: Jon Kabat-Zinn, a biologist at the University of Massachusetts, had an idea to train his medical patients in this Buddhist meditative practice. It is a process of purposefully paying attention to what is happening in the present moment without being distracted by the associations attached to those thoughts or sensations.

5. This ability to "stay in the moment" is not inherent. It takes a lot of practice to get the benefits. It involves quietening distracting thoughts To achieve this, we need to train our mind to go where we want it to go, instead of letting it wander into worry or be taken over by the intrusiveness of tinnitus.

6. In the practice of mindfulness: Thoughts, sensations or feelings which come to mind are not ignored or suppressed. They are not analyzed or judged They are observed intentionally, non- judgmentally, moment by moment, as events in the field of awareness.

7. It is a skill that can be learned and, when practiced in a disciplined manner, can reduce suffering associated with physical, somatic and psychiatric disorders. We learn to be aware of how we move, how we feel (physically and emotionally) how we respond or react to each moment of life.

8. Mumbo-jumbo or science? Does Mindfulness really help? Yes Mindfulness has been successfully used in clinical studies for a variety of conditions

9. These studies include Chronic pain Depression Generalized anxiety Post traumatic stress disorder Rheumatoid arthritis Substance abuse.......

10. Kabat-Zinn, Lipworth, & Burney (1985) 90 patients with chronic pain were trained in mindfulness mediation 10 week stress reduction and relaxation program. Significant reductions in present moment pain, negative body image, inhibition of activity by pain, mood disturbance, anxiety & depression. Significant improvements in activity levels and feelings of self-esteem. Maintained at 15 months post training for all except present moment pain. High compliance rates reported.

11. Studies using mindfulness for chronic pain Astin 1997 - decrease in psychological symptoms, increase in sense of control, compared to the control group. Bruckstein 1999 – improvements in pain questionnaires, somatisation and distress. Sagula 2000 – 20 mins practice per day enough to lower depression & anxiety. Sagula & Rice 2004 – significant reductions in depression & state anxiety, moved quicker through initial stages of grieving. Moriconi 2004 – valuable treatment for both patients and their partners in Fibromyalgia. Leigh et al. 2005 – Freiburg Mindfulness Inventory reliable. Positive relationship between mindfulness & smoking/frequent binge drinking. Plews-Ogan et al. 2005 – effective & long lasting for mood improvement for those with chronic musculoskeletal pain. Massage better for reducing pain. Nash-McFeron 2006 - decrease in headache pain, improvements in aspects of quality of life & a significant improvement in sense of control compared to waiting list group.

12. Studies using mindfulness for chronic pain McCracken et al. 2007 - unrelated to age, gender, education, chronicity of pain. Related to depression & pain- related anxiety. Gardner-Nix et al. 2008 – gains in mental health & pain catastrophizing. Videoconferencing effective. McKim 2008 - significant reduction in rumination, depression, anxiety, psychological distress and medical symptoms. Zautra et al. 2008 - increase in coping and good for recurrent depression compared to education only. Morone et al. 2008 - Significant increase in chronic pain acceptance, activities engagement & physical function compared to control in older people. Morone et al. 2008 - good for pain, attention, sleep & achieving well being in older people with chronic lower back pain. Carmody & Baer 2008 - increase in mindfulness & well- being, and a reduction in stress & symptoms.

13. Let’s consider tinnitus… No single cause of tinnitus No single medical/surgical treatment effective for tinnitus. Large range of psychological effects. Life-style and general health affected. Similarities between tinnitus and chronic pain sufferers.

14. Tinnitus & Chronic Pain Similar Problems with aspects of focus/attention. Perceived lack of control over symptoms. Catastrophic thinking. Maladaptive coping strategies. Similar treatment methods: CBT, relaxation methods, cognitive coping strategies.

15. Natural history of tinnitus Usually resolves/eases through a process of habituation Negative reinforcement enhances perception of tinnitus increases time it is perceived Increases the intrusiveness of tinnitus Increases the distress associated with tinnitus

16. Tinnitus Distress Arises in the same way as distress about anything else, i.e., through the perception of threat. Threat can be perceived in terms of the possibility that something bad will happen, that if the bad thing happens it will be awful, that the person will be unable to cope with this, or that there will be no one to help if the bad thing happens. Implicit in this approach re tinnitus distress is the idea that the perception of threat originates in the person’s thinking.

17. Tinnitus distress Most often distressing thoughts involve cognitive distortions, i.e. the threat is overstated – as a result of processing by a system that generates false positives for survival purposes.

18. Distressing thoughts about tinnitus Can include despair, persecution, hopelessness, loss of enjoyment, a desire for peace and quiet, and beliefs that others do not understand (Wilson & Henry, 1998). Other common thoughts include resentment about persistence of tinnitus, a wish to escape it, & worries about health and sanity (Hallam et al, 1988; Kuk et al, 1990; Wilson et al, 1990).

19. Unhelpful reactions to tinnitus Reacting to tinnitus in the first place is normal. In the long run, the problem is not tinnitus, or the initial reaction to it, but how we continue to react to it. Our reactions to problems can transform what might otherwise be a brief alarm into persistent distress.

20. What do we do to guard against it? Distress will usually give rise to some action designed to reduce that distress. If the distress arises because of a distortion in how we regard the tinnitus, then the behaviour designed to reduce the distress may result in the person not finding out that the thought is overly negative. Keeping safe means you don’t find out about the reality of the threat. Safety can be sought in overt behaviour or in covert (e.g. reassuring thoughts) actions.

21. Safety Seeking Behaviour Avoidance of the situation, e.g., avoidance of noise, use of ear defenders, use of sound. Escape from the situation (e.g. increase in tinnitus intrusiveness) when the anxiety occurs, e.g. through the use of sound. Stay there but neutralise the anxiety through thoughts, e.g. think of something else, or get reassurance.

22. Safety Seeking Behaviour can Maintain Anxiety Seeking reassurance is a common safety behaviour in people with troublesome tinnitus. It can temporarily reduce anxiety about tinnitus But In the long term, at the cost of increasing preoccupation with tinnitus and therefore anxiety - it has a similar effect to checking tinnitus.

23. Safety Seeking Behaviour Can Increase Symptoms Trying to not worry can increase worry, Distraction - when activity is not for its own sake. Inevitably leads to checking. There may be direct physical effects, e.g., excessive use of medicines, avoidance of noise, use of sound (– e.g. excessive use of sound may make tinnitus more intrusive when the sound is turned off).

24. Safety Seeking Behaviour Can Increase Symptoms e.g., you need to lose weight. So you think - don’t think about food.....

25. Example of tinnitus-related safety behaviours Mrs ‘A’ was very anxious that she would be unable to cope with her tinnitus; She believed that if she was exposed to it she would become so anxious she would go mad. She used her sound generator constantly. She added background sound from the TV or radio where ever she went. When she could not do so she hummed to herself. By using sound enrichment in this way she could not find out what would happen if she was exposed to her tinnitus.

26. Conclusion If what we do to solve problems – including tinnitus, does not work or is counterproductive. A different way is needed.

27. Trying not to think about tinnitus doesn’t usually work.

28. What will happen if you don’t try? Let’s ‘discover’ an old technique.......

29. Mindfulness approach to tinnitus? Mindfulness meditation is a technique that can be used successfully in combination with cognitive therapy for tinnitus With mindfulness, we can develop an accurate and pragmatic moment-to-moment awareness of what our experience actually is Once we cease to be locked into reactive habits, the habituation process can proceed.

30. Principles of Mindfulness Relaxing control. Tolerating discomfort. Acknowledging negative emotions. Attention in the present – here and now. Allow feelings to be as they are. Observe private experiences with openness. This makes them less threatening and reduces the impact on your life.

31. Application of Mindfulness Meditation to Tinnitus 2 studies where mindfulness meditation used successfully in managing tinnitus (1) Sweden: Internet-based cognitive behavior therapy for distress associated with tinnitus (2) Wales:

32. Sadlier, Stephens & Kennedy (2008) Treatment of individuals with intrusive tinnitus using a combination of cognitive behavioural therapy & mindfulness meditation. 25 individuals with chronic tinnitus Split into groups: (1) four 1 hour sessions of CBT/meditation (2) waited 3 months, then treated Significant reductions in tinnitus post- treatment.

33. 4-6 month follow-up : Sadlier, Stephens & Kennedy (2008)

34. So how does it work?

35. Mindfulness meditation in practice Different strategies Start the practice of mindfulness with developing self-awareness of the breath Body Scan - gentle purposeful mental tour of the body becoming aware of each part of our body sequentially finally focussing awareness on one part eg left foot. If mind drifts, bring it back to the area of focus, to the present moment

36. 2 exercises Consider a raisin........ Consider your breathing.......

37. The way forward? Help tinnitus patients to recognise the role of thoughts in provoking distress. Help patients to recognise thoughts as thoughts – and so become less distressed by them. Encourage patients to stop fighting tinnitus. Encourage patients to meditate on tinnitus. Encounter it rather than avoidance. Test their thoughts and realise the spectrum that is tinnitus.

38. Mindfulness-based cognitive therapy to reduce recurrence of depression Participants able to develop a different (‘decentred’) relationship to their experience, so that their depression-inducing thoughts could be viewed from a wider perspective as they were occurring.

39. By breaking the link between a negative experience and the negative thinking it would normally have triggered, it allows the individual to develop the capacity to allow distressing mood, thoughts and sensations to come and go, without having to battle with them. The use of mindfulness meditation, therefore, is a strategy that once learned, an individual can apply to other stressful or anxiety-related situations of which tinnitus is a case in hand.

40. As tinnitus is uncoupled from the experienced reaction Reduce the experience of suffering and can be employed at times associated with heightened tinnitus awareness. As the reaction to tinnitus is an individual one, this approach can be successfully tailored to the individual in order to address the particular needs and problems of the individual with tinnitus.

41. Dublin Buddhist Centre Blue Sky