Methodology For Pinpointing Tinnitus Distress

Is the distress that you are experiencing related to your tinnitus and hyperacusis/misophonia symptoms or they are related to other underlying psychological issues?

Recent research shows that abnormal scores on the tinnitus questionnaires do not always mean that the patient is currently experiencing distress related to their tinnitus and/or hyperacusis (Aazh et al. 2018). Specialized version of cognitive behavioural therapy (CBT) for tinnitus and/or hyperacusis rehabilitation which is offered in Dr. Aazh’s clinic is only needed if the patient experiences current tinnitus and/or hyperacusis-related distress, in the other words if their day-to-day activities or mood are affected due to their tinnitus or sound intolerance. A pioneering study by Dr. Aazh and his tinnitus team showed that about 70% of patients with abnormal scores on the hyperacusis questionnaire (HQ) and/or tinnitus handicap inventory (THI) presented with tinnitus- and/or hyperacusis-related distress warranting specialized CBT (Aazh & Moore 2018b). For 30% of patients there was no current tinnitus and/or hyperacusis-related distress, although approximately half of them were experiencing some form of emotional distress which they assumed was due to their tinnitus. For these patients (15% of the total) it was agreed that the emotional disturbances they were experiencing did not seem to be related to their tinnitus and/or hyperacusis and were more likely to be related to an underlying psychological disorder. Hence, they were referred for further psychological evaluations and treatment.

The interesting point is that there was no statistically significant difference in the scores on questionnaires between the patients who shown to have current tinnitus and/or hyperacusis-related distress (as established based on the in-depth interview, see details the section below) and patients whose tinnitus did not interrupt their day-to-day activities or affect their mood. Therefore, use of questionnaires alone does not help to accurately identify patients who might benefit from specialized CBT and in-depth interview is needed.

The methodology for identifying the distress linked to tinnitus, hyperacusis and misophonia

Dr. Aazh proposed that in-depth interviews should be used to explore the impact of tinnitus and/or hyperacusis/misophonia on the patient’s life (Aazh et al. 2018; Aazh & Moore 2018b; Aazh & Moore 2018a). Dr. Aazh’s approach is unique because it encourages the use of in-depth interviews in clinical setting in order to explore the individual’s cognitive, behavioural, and emotional reaction to tinnitus or certain sounds (in the case of hyperacusis and misophonia). During the in-depth interview, patients are encouraged to talk about a typical day (e.g., tell me a bit more about how your tinnitus and/or hyperacusis affect your activities and/or mood on a typical day?). The aim of this strategy is to provide an opportunity for the patient to reflect on the way that they currently manage their tinnitus and/or hyperacusis and to identify any areas for improvement. The approach is collaborative, with a strong emphasis on the clinician and patient exploring the problem together. Throughout, the patient is encouraged to make discoveries with careful questioning from the clinician rather than the clinician giving information and advice. If the tinnitus and/or hyperacusis do not interrupt the patient’s day-to-day activities or affect their mood, it will be concluded that specialized CBT is not needed. Such patients will be discharged. If the conclusion is that the distress the patient experiencing is due to an underlying psychological disorder, not necessarily to tinnitus/hyperacusis/misophonia, then the patient needs to be referred to mental health services. If in-depth interview show that tinnitus and/or hyperacusis does affect the patient’s activities or mood in a typical day, then this should be further explored and specialized CBT to be considered.


Aazh, H., Knipper, M., Danesh, A. A., et al. (2018). Insights from the third international conference on hyperacusis: causes, evaluation, diagnosis, and treatment. Noise Health, 20, 162-170.

Aazh, H., & Moore, B. C. J. (2018a). Effectiveness of audiologist-delivered cognitive behavioral therapy for tinnitus and hyperacusis rehabilitation: outcomes for patients treated in routine practice American Journal of Audiolgy, [Epub ahead of print], 1-12.

Aazh, H., & Moore, B. C. J. (2018b). Proportion and characteristics of patients who were offered, enrolled in and completed audiologist-delivered cognitive behavioural therapy for tinnitus and hyperacusis rehabilitation in a specialist UK clinic. Int J Audiol, 57, 415-425.

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