Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences 40 Cognitive Behavioural Therapy as Guided Self-help to Reduce Tinnitus Distress VIKTOR KALDO ACTA UNIVERSITATIS UPSALIENSIS ISSN 1652-9030 UPPSALA ISBN 978-91-554-7235-1 2008 urn:nbn:se:uu:diva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o Volmar, Arvid and Susanna Included Papers This thesis is based on the following papers. I. Kaldo-Sandström, V., Larsen, H. C., & Andersson, G. (2004). Internet- based cognitive-behavioral self-help treatment of tinnitus: Clinical effectiveness and predictors of outcome. American Journal of Audiology, 13, 185-192 II. Kaldo, V., Levin, S., Widarsson, J., Larsen, H. C., & Andersson G. (In press). CBT for tinnitus – in a group and via the Internet. A randomised controlled trial with 1-year follow-up. Behavior Therapy. III. Kaldo, V., Renn, S., Rahnert, M., Larsen, H. C., & Andersson, G. (2007). Use of a self-help book with weekly therapist contact to reduce tinnitus distress: a randomized controlled trial. Journal of Psychosomatic Research, 63, 195– 202. IV. Kaldo, V., Richards, J., & Andersson, G. (2006). Tinnitus Stages of Change Questionnaire: Psychometric development and validation. Psychology, Health & Medicine, 11, 483 – 497 Contents Introduction...................................................................................................... 11 Tinnitus ....................................................................................................... 11 What is tinnitus? ..................................................................................... 11 Measuring tinnitus .................................................................................. 12 Tinnitus pitch matching ..................................................................... 13 Tinnitus loudness matching ............................................................... 13 Minimum masking level (MML) ....................................................... 13 Prevalence of tinnitus ............................................................................. 13 What causes tinnitus? ............................................................................. 14 Psychological models and theories......................................................... 15 Habituation theory.............................................................................. 15 The neurophysiological model........................................................... 16 A comparison between the models .................................................... 16 Tinnitus distress...................................................................................... 17 Sleep problems................................................................................... 17 Problems with concentration and memory......................................... 17 Emotional problems, psychiatric diagnoses and stress ...................... 18 Hearing deficit and sensitivity to sound............................................. 19 Audiometric factors and distress........................................................ 19 Measuring tinnitus distress................................................................. 20 Treatments for tinnitus............................................................................ 20 Medical treatments aimed directly at tinnitus .................................... 20 Medical treatments aimed at tinnitus distress .................................... 21 Audiological treatments for tinnitus................................................... 22 Complementary medicine .................................................................. 23 Psychological treatments for tinnitus................................................. 23 Cognitive behavioural therapy for tinnitus ............................................. 24 Self-help and guided self-help..................................................................... 27 Introduction to self-help ......................................................................... 27 A definition of self-help and guided self-help........................................ 28 Definition of self-help........................................................................ 28 Definition of guided self-help ............................................................ 29 Different forms of self-help.................................................................... 30 Self-help books .................................................................................. 30 Computer-based self-help .................................................................. 30 Outcome of self-help and guided self-help............................................. 31 Outcome of self-help in general......................................................... 31 Self-help studies relevant for tinnitus distress ................................... 32 The role of the therapist.......................................................................... 34 Cost-effectiveness................................................................................... 34 Drop-out from treatment and loss of post-treatment data....................... 35 Critique of self-help................................................................................ 35 Pros and Cons of self-help ................................................................. 36 Coping, readiness to change and predicting outcome ................................. 37 Coping strategies .................................................................................... 37 Predictors of treatment success............................................................... 38 Stages of Change and the transtheoretical model ................................... 38 The Empirical Studies...................................................................................... 40 Aims........................................................................................................ 40 Overall aim of the thesis .................................................................... 40 The aims of the specific studies ......................................................... 40 Methods .................................................................................................. 41 Design and procedure......................................................................... 41 Participants......................................................................................... 42 Measurements .................................................................................... 43 Treatment ........................................................................................... 47 Data analyses...................................................................................... 51 Results .................................................................................................... 52 Study I – Clinical setting trial ............................................................ 52 Study II – Internet versus group treatment......................................... 52 Study III – Self-help book.................................................................. 53 Overview of outcome, attrition and drop-out in study I, II and III .... 54 Study IV – Stages of Change ............................................................. 55 Discussion............................................................................................... 56 Study I – Clinical setting trial ............................................................ 56 Study II – Internet versus group treatment......................................... 56 Study III – Self-help book.................................................................. 57 Study IV – Stages of Change ............................................................. 58 General Discussion .......................................................................................... 60 Treatment effects on tinnitus distress ..................................................... 60 Therapist time-effectiveness................................................................... 62 Treatment effects on depression, anxiety, sleep and stress..................... 62 Therapist contact..................................................................................... 63 Predictors of treatment success............................................................... 64 Treatment credibility .............................................................................