Audiologist-Delivered CBT for Tinnitus,

Hyperacusis and Misophonia

Hashir Aazh
info@hashirtinnitusclinic.com
Objectives

01 02 03
Introduce a 14-session Explore characteristics Discuss trends in
specialised of patients with tinnitus, treatment outcome.
rehabilitation hyperacusis and
programme based on misophonia who
CBT (delivered by enrolled in this
audiologists via video programme.
calls).

4
Therapy for tinnitus has a set of long-term goals

1- Learn about tinnitus and factors related to it.

2- Develop willingness to live their satisfying life even with tinnitus.
3- Cooperate with medical, psychological and rehabilitative treatments offered to them.
4- Reduce fear of tinnitus.
5- Learn and implement CBT skills for tinnitus management.
6- Develop confidence in being able to carry out their day-day tasks, rest and relax and enjoy
their life even with tinnitus without the need for avoidance behaviours.
7- Reduce tinnitus-related emotional disturbances.
8- Reduce tinnitus-related sleep difficulties, concentration problems, and bodily sensations.
9- Develop skills for dealing with setbacks.
10- Integrate CBT skills to their lifestyle.

5
Therapy for sound intolerance has a set of long-term goals.
1- Learn about the presenting type (s) of sound intolerance (i.e., hyperacusis, misophonia, or
noise sensitivity) and factors related to it.
2- Cooperate with medical, psychological, and rehabilitative treatments offered to them.
3- Develop willingness to carry on with their day-to-day life even in presence of sounds that
trigger intrusive thoughts and emotions and without using avoidance behaviours or rituals.
4- Learn and implement CBT skills for management of the presenting type (s) of sound
intolerance.
5- Develop confidence in being able to carry out their day-day tasks, rest and relax and enjoy
their life even when exposed to the trigger sounds without the need for avoidance behaviours.
6- Reduce the intensity, frequency and duration of episodes of reaction to sounds.
7- Reduce noise-related emotional disturbances.
8- Reduce impact of sound intolerance on relationships, daily activities, leisure time,
concentration, and life enjoyment.
9- Develop skills for dealing with setbacks.
10- Integrate CBT skills to their lifestyle. 6
Sessions Content summary Sessions Content summary
1 Rapport building 8 Review counter-statements
Getting to know the patient Review and escalate SEL
Semi-formulation
9 NATs and PATs
2 Formulation Review and escalate SEL
Sharing the formulation
Exposure and ritual menus 10 Introduce Know, Keep on, Identify,
Substitute (KKIS)
3 CBT psychoeducation
Diary of Thoughts and Feelings (DTF) 11 Review KKIS
Stop avoidance, Exposure, Learn from Progress review
it (SEL) 12 Review KKIS and use combined counter
4 Review DTF statements
Review and escalate SEL Who is your opponent?
5 Exploring thoughts on DTF 13 Review KKIS and problem solving
Identifying hot thoughts How to manage setbacks
Review and escalate SEL 14 Final review
6 Psycho-education on thought CBStyle
distortions
Identify thought distortions in DTF
Review and escalate SEL
7 Introduce counter-statements
7
Review and escalate SEL
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 Tinnitus Hyperacusis Misophonia
Avoidance behaviours • Avoid staying in quiet • Over use of ear • Avoid eating with family
rooms protection • Avoid spending time
• Avoid certain day-to-day • Avoid going to certain with the person who
activities places triggers them

Rituals • Search the internet for a • Keep measuring the • Telling people to not to
cure despite knowing sound levels make noise knowing
the unreliability of • Burning lavender oil that it may not be
many claims on various feasible
websites. • Giving the person who
• Seeking reassurance made the noise a look
over and over again
despite already knowing
what the answer will
be.

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Key messages
• Patients experiencing distressing tinnitus, hyperacusis and
misophonia can have template-based formulation that can be used by
therapists.
• Different pattern and types of thoughts and reactions may be
experienced among patients with tinnitus, hyperacusis and
misophonia which can feed into their formulations.
• In most patients, a distinction between initial reactions and follow on
reactions can be made.
• All three conditions seem to have a series of avoidance behaviours
and rituals that need to be identified during the treatment.
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 What behaviours and Negative thoughts Predict how The actual level of
rituals I should stop? to be tested difficult will it be difficulty falling
to fall sleep sleep
(0-100%) (0-100%)
“0” means not
difficult at all, “0” means could
“100” means no fall into sleep
sleep! within 30 minutes,
“100” means no
sleep at all!
(Record this before DND cards (Did
exposure) Not Do it) DND
cards

(Record this after

exposure)
SEL Tinnitus Behaviour: listening to
nature sounds at night
Tinnitus will be
loud 9/10
9/10 Night 1: Monday
9/10
1.5hours
Falling asleep 1.5-2 hours 50%
will be delayed 40%
20%
Frustrated 60% (100% Night 2: Tues
shouting out of 9/10
frustration) 1 hours
Next day tired 50% (100% can’t 25%
move) 30%
Next angry 10% (100% 0%
smashing things) Night 3: Wed
9/10
0.75 hours
10%
25%
0%
Night 4: Thurs
9/10
0.5hours
10% 15
 What behaviours and Negative thoughts Predict how The actual level of
rituals I should stop? to be tested difficult will it be difficulty
(0-100%) (0-100%)
“0” means not
difficult at all, “0” means no
“100” means difficulty, “100”
impossible. means impossible.

(Record this before (Record this after

exposure) exposure)
*3 DND cards*
Behaviour: List 3 NATs o be Day 1: Tuesday
tested 30th March

SEL 1- Use hoover

2- Gardening Pain in my ear 80% (100% is the
max pain)
70%
90%
½ day
Hyperacusis Headache
Recovery in bed
90%
3 days
Day 2: Wednesday
31st March
30%
40%
0 day
Day 3: Thursday
1st April - Rest
Day
%
%
days
Day 4: Friday 2nd
April
50%
80%
1 day
Day 5: Saturday 16
 What behaviours and Negative thoughts to Predict how The actual level of
rituals I should stop? be tested difficult will it be difficulty
(0-100%) (0-100%)
“0” means not
difficult at all, “0” means no
“100” means difficulty, “100”
impossible. means impossible.

(Record this before (Record this after

exposure) exposure)
*2 DND cards*
Did Not Do it

SEL
Behaviour: List 3 NATs o be Time 1:
Leaving the area when tested 20%
my son is triggering me 20%

Misophonia **not to replace it with

some other behaviours
I will get irritated

This will impact on

80% (100% the
highest)
80% (100% means
30%
Time 2:
50%
e.g., telling the person my concentration. no concentration) 40%
to stop, etc. 50%
I will not be able to 100% (100% Time 3:
enjoy the time. means enjoy 60%
nothing) 40%
60%
Time 4:
70%
30%
70%
Time 5:
30%
20%
30%
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Time 6:
Key messages

• Using SEL, patients can

change their
behaviours/rituals and test
some of their thoughts.
• SEL also helps to improve
patient’s tolerance of the
uncomfortable feelings that
they may experience.
• Learn from their
experience!
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 Know Keep on Identify Substitute
Thursday 19th August My emotion was why now all of a
11pm – Lying in bed Frustration as I was so sudden after so long it Failing is a common
trying to fall asleep – tired had started to bother me thing. We learn from it.
tinnitus was 9/10 and again. Failing?
was really bothering me What is good: -
I am tired. 1. Frustration can This is starting all over I have already taken
lead to taking again and more positive steps in
action to use sleepless nights gain manging tinnitus.
my CBT. Tinnitus goes up and
down and I have the
2. It is a normal tools to manage my
reaction to feel reaction.
frustrated by
things we feel
are beyond our I will be awake all I am resting. Second
control. night. If I lose my sleep best.
I will be unproductive
3. By feeling this at work and feel
emotion, I horrible all day.
become more

KKIS Tinnitus
tolerant to it

22 May 2022 My emotion is As much as it takes As much as it takes

Tinnitus loud 9/10 in frustration and
bed annoyance Because of tinnitus I I am resting….
11 pm About 5 to 10 seconds cannot sleep
It took me 3 hours to 1- This is a
fall sleep common I will not be in great Future is unpredictable.
1 second human emotion form tomorrow Even if I am tired, I still
2- It will subside will be able to perform
Feeling this emotion well in my work.
improves my tolerance
to it There is no way I will Future is unpredictable.
be able to drive for 3 I can always find some
hours being this tired. time to rest and
recharge so I will be
safe to drive.

I must always be at my My efficiency will go

peak efficiency up and down.

I mustn’t feel tired Being tired is normal at

times.

I am unlovable I am loved by many

people. My value as a
person remains with me
for as long as I live
regardless of what
others feel for me. 19
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 Know Keep on Identify Substitute

Reading/ muffled *spend 5 to 10 why does there It's possible to get

sounds from the seconds here. have to be noise all things done even
kitchen/ I'm angry I am feeling angry. the time here? with interruptions
and frustrated 1- this is a common
human emotion. I shouldn’t have to This type of thing
*you need to
2- the emotion will deal with this happens all the time.
immediately
subside on its own. Everyone else has to
recognise that it is
hear this
3- by feeling it I am

KKIS
time to KKIS.
improving my
tolerance to it.

Misophonia She makes too

much noise
She is just trying to
do her job

I can’t focus on I can focus by about

what I'm reading 70 %

Life is unfair
Considering everything
my life is more fair than
unfair.

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 Know Keep on Identify Substitute
3/21 **I am feeling I feel panicky which This is just an emotion.
LOUD CONCERT stressed and means I am in danger. I am using appropriate
Although I was using fearful** ear protection.
earplugs I still was
1- this is a common
feeling uncomfortable. It will ruin my evening I can still enjoy 50% of
human emotion
the evening
2- by feeling this way
I am improving my
If I leave early my What other people
tolerance to this
family will be very think is out of my
emotion. angry and control.
3- these emotions disappointed with me
will subside on their

KKIS
Most people
own. I am letting them
understand if
down.
someone has a

Hyperacusis problem. It is
inevitable that
sometimes during
my life I let people
down or hurt them.
This applies to them
too.

I am only human and

I am less of a man.
have strength and
weaknesses

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Key messages
• KKIS can help patients to
understand that they cannot
simply get rid of their
uncomfortable emotions. The
more they push them away the
more they get stuck!
• KKIS helps them in a systematic
way to accept their emotions and
stop them from snowballing by
identifying irrational thoughts and
changing them.

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Method
• Ethical Approval
The study was approved by the University of Surrey ethics committee (Project ID: FHMS 21-22 147
EGA).
• Design
Retrospective analysis of available clinical data.
• Study population
42 consecutive patients who enrolled in audiologist-delivered CBT for tinnitus, hyperacusis or
misophonia in 2021-22.
Mean age was 36.3 years old (SD=19.8, ranged between 8 and 69 years old).
52% were female.
76% were over 16 years old (considered “adults” in this context).

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Assessment

Diagnosis of distressing tinnitus, hyperacusis and misophonia

• Case history
• In-depth interview
Explore symptoms and their impact on the individual i.e., whether it interrupts their day to day
activities and/or impact on their mood.

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Distressing tinnitus is defined as tinnitus that has a significant effect on the person’s everyday life. For
diagnosis of distressing tinnitus, a person needs to display at least one of the first four characteristics listed
below, in addition to characteristic 5 (i.e., (item 1 or 2 or 3 or 4) + item 5).

1. Tinnitus interrupts some day-to-day tasks or activities.

2. Tinnitus adversely affects their mood.
3. Tinnitus adversely affects resting, relaxing or sleeping.
4. The person uses avoidance behaviours or rituals in order to cope with their tinnitus.
5. The effect on the person’s activities, mood, or behaviours is related to the experience of
tinnitus and is not better explained by other underlying medical or psycho-social conditions.

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Diagnostic Results
Diagnosis n Percentage
Tinnitus alone 10 23.81 %
Hyperacusis alone 2 4.76 %
Misophonia alone 16 38.1 %
Tinnitus and hyperacusis 11 26.19 %
Hyperacusis and misophonia 1 2.38 %
Tinnitus, hyperacusis and misophonia 2 4.76 %
Total 42 100 %

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Self-report questionnaires (new)

Hyperacusis Misophonia Sound Sensitivity

Tinnitus Impact
Impact Impact Symptoms
Questionnaire
Questionnaire Questionnaire Questionnaire
(TIQ)
(HIQ) (MIQ) (SSSQ)

Screening for
Anxiety and 4C Tinnitus 4C Hyperacusis 4C Misophonia
Depression in Management Management Management
Tinnitus (SAD-T)

Adult (>=16) and Parent versions (<16)

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Other self report questionnaires for tinnitus and hyperacusis

Tinnitus Handicap Inventory (THI)

Visual Analogue Scale (VAS) of tinnitus loudness

VAS of tinnitus annoyance

VAS of the effect of tinnitus on life

Hyperacusis questionnaire (HQ)

Inventory of Hyperacusis Symptoms (IHS)

Insomnia Severity Index (ISI)

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Screening psychological questionnaires

MINI - SOCIAL
Short Health
PHOBIA
PHQ-9 GAD-7 Anxiety Inventory
INVENTORY (MINI-
(sHAI)
SPIN)

The Obsessive– Penn State Worry The Panic Disorder

Compulsive Questionnaire: Severity Scale –
Inventory: Short abbreviated Self Report Form
Version version (PSWQ-AR) (PDSS-SR)

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Results (new questionnaires)
Diagnosis/ Tinnitus alone Hyperacusis alone Misophonia alone Tinnitus & Hyperacusis & Tinnitus,
Questionnaires Hyperacusis Misophonia Hyperacusis &
Misophonia
Age 49.8 (SD=15) 26 20.7 (SD=13.6) 51.7 (SD=12) 13 26
Gender 50/50 0/100 47/53 50/50 Female 50/50
(male/female)
TIQ 15 (3.7) 10 0 13.2 (SD=4.5) - 18
HIQ 6.5 (7.7) 23 6.6 (SD=7) 20.4 (SD=3.4) 23 21
MIQ 1.3 (2.4) 0 19 (SD=5) 8 (SD=7.5) 24 17
SSSQ 2.3 (3.3) 11.5 3.4 (SD=2.4) 11.3 (SD=4.2) 14 13
SAD-T 8.1 (4.2) 5 5.3 (SD=3.8) 9.8 (SD=2.5) 10 6.5

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Results
Diagnosis/ Tinnitus Hyperacusis Misophonia Tinnitus & Hyperacusis Tinnitus,
Questionnaires alone alone alone Hyperacusis & Hyperacusis &
Misophonia Misophonia
THI 78 (SD=17) 0 - 65 (SD=17.2) - 64 (SD=11.3)
HQ 13 (SD=9.4) 33 22.3 26 (SD=8.5) - 21.5 (SD=4.5)
(SD=10.5)
IHS 47.5 86 64.6 (SD=18) 77.9 (SD=16.5) - 78 (SD=5.6)
(SD=22.6)
ISI 21.5 4 7.5 (SD=4.6) 16.9 (SD=8.3) - 10 (SD=8.5)
(SD=4.8)

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Key messages
• Patients with misophonia as diagnosed via in-depth interview had
considerably higher MIQ score compared to those who did not have
misophonia.
• Patients with hyperacusis as diagnosed via in-depth interview had
higher scores on HIQ and SSSQ.
• IHS and HQ seem to be picking up problems related to hyperacusis
and misophonia.

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Tinnitus Alone and tinnitus combined with hyperacusis and/or Pre-treatment Post-treatment ES
misophonia
TIQ (n=13) 14.4 (SD=3.5) 5 (SD=4.8) 1.47
4C Tinnitus (n=21) 17.7 (SD=14.7) 54.9 (SD=31.6) -1.24
THI (n=15) 71 (SD=17.3) 24.8 (SD=18) 1.61
VAS Loudness (n=15) 7.7 (SD=1.4) 5 (SD=2.5) 0.99
VAS Annoyance (n=15) 8.5 (SD=1.2) 4 (SD=2.5) 1.61
VAS Effect on Life (n=15) 8.3 (SD=1.6) 3.5 (SD=3.13) 1.62
ISI (n=19) 16 (SD=7.2) 6.8 (SD=5.5) 1.2
SAD-T (n=14) 9 (SD=2.7) 2.35 (SD=2.3) 1.88
PHQ-9 (n=12) 15.1 (SD=6.5) 5.6 (SD=5.7) 0.91
GAD-7 (n=10) 14.3 (SD=5.6) 6.2 (SD=4.9) 1.07
sHAI (n=9) 22 (SD=9.6) 16 (SD=11.5) 0.83
MINI-SPIN (n=8) 3.6 (SD=3.5) 1.4 (SD=1.5) 0.59
OCI-SV (n=9) 12.7 (SD=7) 9.4 (SD=9.6) 0.37
PSWQ-AR (n=10) 28.6 (SD=8.5) 22.2 (SD=8.2) 1.04
PDSS-SR (n=9) 3 (SD=2.3) 0 1.9

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All with hyperacusis with or Pre- Post- ES
without tinnitus/misophonia treatment treatment
HIQ (n=11) 21.2 6.2 (SD=6.8) 2.16
(SD=2.35)
4C Hyperacusis (n=8) 8.95 42.8 -1.84
(SD=7.9) (SD=36.6)
HQ (n=8) 28.75 16 (SD=11.4) 0.87
(SD=5.1)
IHS (n=7) 83 (SD=9.2) 50 (22.9) 1.6

SSSQ (n=10) 11.6 3.4 (3.3) 1.6

(SD=3.7)
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All with misophonia with or without Pre-treatment Post-treatment ES
tinnitus/hyperacusis
MIQ (n=19) 19.3 (SD=4.8) 10.4 (SD=6.8) 1.45
4C Misophonia (n=17) 9.3 (SD=9.4) 39.6 (SD=24.4) -1.62
SSSQ (n=16) 4.4 (SD=3) 2.25 (SD=1.3) 0.63
SAD-T (n=17) 5.35 (SD=3.8) 2.8 (SD=2.96) 0.73
PHQ-9 (n=8) 10 (SD=4) 6.5 (4) 0.86
GAD-7 (n=6) 12.5 (SD=4.8) 9.5 (SD=5.2) 0.63
sHAI (n=6) 19.2 (SD=9.4) 15.2 (SD=9.6) 0.86
MINI-SPIN (n=5) 3.6 (SD=2.7) 3 (SD=3.5) 0.51
OCI-SV (n=6) 18.33 (SD=12.4) 18.5 (SD=13.4) -0.031
PSWQ-AR (n=7) 24 (SD=7.7) 19.7 (SD=6.9) 0.96
PDSS-SR (n=7) 3 (SD=3) 1..6 (SD=2.6) 0.89
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Diagnosis/ Tinnitus Misophonia Tinnitus &
Questionnaires alone alone Hyperacusis
SAD-T 78% to 0% 59% to 37.5% 100% to
44.5%
sHAI 30% to 25% 43% to 33% 92% to 67% Change in
MINI-SPIN
OCI-SV
22% to 0%
11% to 0%
57% to 40%
43% to 33%
25% to 0%
25% to 17%
proportion of
PSWQ-AR 45% to 20% 71% to 43% 83% to 50% abnormal scores
PDSS-SR
Suicidal
0% to 0%
44.5% to 0%
0% to 0%
57% to 14%
8% to 0%
90% to 28.5%
on psychological
ideations questionnaires
Meeting 90% to 40% 41% to 41% 100% to 70%
“caseness” for
mental health
services

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Key messages
• Large ES on disease specific measures.
• ES on SAD-T was bigger for tinnitus and hyperacusis compared to
misophonia. Tinnitus and hyperacusis patients started with much
higher scores.
• Among misophonia patients OCD and social anxiety symptoms had
very little change. Over 30% still abnormal at discharge.
• At discharge more than 40% of patients in all 3 groups still meet the
“caseness” criteria.
• Although manage their symptoms better, longer term general
psychotherapeutic support may be needed.

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Trends?

• 45.5% took drug and/or counselling

• Change in TIQ was 12 (SD=6) among those who took psychiatric medication
or therapy in addition to tinnitus-focused CBT compared to 6.5 (SD=6.4)
among those who did not.
• HIQ or MIQ to lesser extent but still better among those who took
psychiatric medication or therapy: 15.4 (SD=8.3) and 9.5 (SD=7) compared
to 14.7 (SD=7.6) and 8.6. (SD=6.3), so there may be a trend.
• Change in MIQ in children was 10 (SD=7) compared to 6.5 (SD=8) in adults.
• Change in HIQ in children was 4.6 (SD=8.2) compared to 9.3 (SD=8.8) in
adults.

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Conclusions
• Template-based formulation can be used by therapists.
• All three conditions seem to have a series of avoidance behaviours and rituals that need
to be identified during treatment.
• SEL and KKIS can be used as parts of CBT.
• MIQ, HIQ and SSSQ seem to be more specific compared with HQ and IHS.
• Patients with tinnitus and hyperacusis had more severe anxiety/depression symptoms
but social anxiety and OCD seems to be higher in patients with misophonia.
• Large ES on disease specific measures. Data can be used for design of future trials.
• Effect of medication/counselling in addition to targeted CBT as well as adults vs children
efficacy to be assessed.
• At discharge more than 40% of patients in all 3 groups still meet the “caseness” criteria.
• Although manage their symptoms better, longer term general psychotherapeutic support
may be needed.

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