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ATRR_2018_Why_and_how_does_emotional_stress_affect_tinnitus_FINAL.pdf

Stress – which of us does not know the daily hassle: missed train, lost car keys, being late for an appointment or perhaps water damage in the cellar. Our bodies react to stressful events in individual ways and the reactions can range from a flushed face or sleepless night to a heart attack. But tinnitus? Can going through a divorce produce ringing in the ear? Can a death or a sickness in family make the already existing tinnitus intolerable? Where is the connection?

The book Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals published in September 2017 by Springer Nature, addresses these types of questions so that the health professionals better understand and consequently improve the treatment of their patients. The intention of this book was to provide a comfortable platform for physicians and audiologists to increase their knowledge regarding emotional stress and tinnitus. By the way – did you know that the health professionals who see patients with tinnitus differ from country to country? For instance, in the UK, tinnitus patients are seen mainly by ENT and audiology specialists, whereas in Italy, predominantly by general practitioners (1). Regardless of these differences, none of above specialists acquires routine training in psychology or in the treatment of stress-related conditions. By no means has this made them bad specialists – not at all! They are experienced professionals but it does not hurt to know more on the subject of stress and tinnitus. This article provides a brief summary of the book chapters and highlights their relevance to clinical practice.

A journey through the nine chapters covers various aspects of emotional strain. In the ntroduction, we clarify how and why all the issues discussed in the book come together (1).

The chapter Stress and Glucocorticoid Action in the Brain and Ear: Implications for Tinnitus explains how stress hormones work in general and how they could contribute to tinnitus and tinnitus-induced distress (2). Our bodies produce stress hormones in response to emotional strain. The stress hormones not only make our hearts beat faster and our blood pressure go high but can also affect the functioning of many other systems, for instance our immunity. People who have stressful jobs very often complain that during holidays, instead of enjoying the sun and family, they get flu and have to spend the time in bed being sick, which is unfortunate. The main reason for this is that stress hormones suppress the immune reactions. Once the job-related stress is over – which is during the holiday – the concentration of stress hormones goes down, the immune system is set free and starts to fight, whereas the person feel miserable exactly during their time off.

For decades, it has been known that the cells of the immune system can ‘see’ and ‘react’ to stress hormones. Can the cells of the auditory system also react to stress hormones and if yes – how? By now we know that they can, but the precise reactions induced by stress hormones in the ears and auditory brain have not been clarified and are the subject of intense research.

Stress-Related Psychological Disorders and Tinnitus is a chapter that reviews psychological conditions often diagnosed in tinnitus patients (3). Did you know that every second patient with tinnitus suffers additionally from depressive moods or anxiety symptoms? Such symptoms are often a result of stress. However, which is the cause and which the consequence? Is it the tinnitus that induces psychological problems or do the existing problems lead to tinnitus? The answer to this question is not entirely clear yet, but there was an important promising observation made by clinical research: therapy for depressive, anxious or other psychological conditions helps the patients combat their tinnitus. Research also recognises that emotional stress worsens or even initiates psychological conditions and this is why relaxation techniques are used universally in addition to the disorder-specific treatment.

Circadian Influences on the Auditory System contains new information about how a 24-hour rhythm affects our hearing and possibly tinnitus (4). A daily rhythm, which controls being sleepy in the evening and waking up in the morning, is an elementary housekeeping mechanism for our bodies. Similar to the clockwork that keeps the watch ticking, daily rhythms (also known as diurnal rhythms) are controlled by several mechanisms. One of these mechanisms involves the stress hormone – cortisol, which has already been mentioned.

The basal concentration of cortisol in our bodies changes, being very low in the evening and rising shortly before we awake. Stress interferes with this basal production of cortisol and this interference may in turn induce insomnia, well-known to everyone who has been upset in the evening. In addition to stress hormones, the presence or levels of many other substances and proteins in our bodies are regulated in a daily rhythm fashion.

Recently, researchers discovered a unique daily rhythm system in the inner ear of experimental animals. This discovery helps us to understand why our ears are more vulnerable to acoustic injury at night, as opposed to the daytime. The role that daily rhythms may play in tinnitus has only started to be explored but we already know that in some cases, tinnitus perception disrupts the sleep routine of affected patients and in this way negatively interferes with the diurnal rhythm.

The chapter Animal Models of Stress and Tinnitus deals with basic research models used to understand tinnitus (5). We all love all creatures great and small, but so far, nothing that could replace the use of animals in tinnitus research has been invented. Without animal models, no research could be done and no progress would be possible in the field of tinnitus. However, the results obtained with the use of animals cannot be translated one-to-one to clinics. The problem is that tinnitus is the subjective perception of a phantom sound. A person suffering from tinnitus can describe it and can say if it is disturbing or not. An animal cannot say much on the subject. Therefore, researchers have designed complex methods to measure the presence of tinnitus in experimental animals. Understanding such methods is essential for the translation of results obtained in laboratory to the clinical life.

Fever, high blood pressure, arrhythmia, kidney insufficiency – they can all be measured in an objective way. But tinnitus? So far, all methods used to measure tinnitus are subjective. The lack of objective markers for tinnitus complicates clinical studies and the everyday monitoring of patients alike. This situation prompted some researchers to look for so-called biomarkers in the blood of people with tinnitus and that is the topic of the chapter Stress-Related Blood Biomarkers (6). The idea behind it is quite simple – find a substance in blood, the levels of which would correlate with the subjective complaints of the patient.

The problem is what to look at? There are thousands of molecules in blood. Since tinnitus is associated with emotional stress and this association seems to be distinctive, tinnitus research started to target molecules known to be modulated by stress. Yet again, cortisol was on the top of the list of substances to be used as a marker, but the results, although promising, are more individual-oriented rather than providing a universal answer for the population affected by tinnitus. Currently, other substances are being scrutinised – proteins used for communication between the cells of immune or nervous systems. The research goes forward but as of today, we still have no definite candidate for an objective blood marker in tinnitus.

Whilst blood biomarkers are still being searched for, it is essential to somehow measure tinnitus. Audiologists measure the audiological properties of tinnitus such as loudness or pitch, however, tinnitus distress or discomfort also has to be measured. How do we do that? Upon admission, the patient usually fills in (alone or with the help of a health professional) a so-called psychometric instrument. A psychometric instrument is a set of carefully chosen and standardised questions to which the answers (usually ‘yes’, ‘no’, ‘don’t know’) have a numerical value. The final score of any tinnitus-oriented psychometric instrument translates into a diagnosis and grading of tinnitus severity.

The basic principle is similar to that in a Cosmopolitan quiz, but of course much more complicated and much more serious – the psychometric instruments are about the health and well-being of patients. The instruments used for tinnitus diagnosis are carefully calibrated and tested (validated). In the chapter Psychometric Assessment of Tinnitus Patients Within Clinical Practice Settings (7), the authors describe the selection of psychometric instruments related to stress and used to assess the severity of tinnitus related distress. The authors discuss the choices in terms of how to use them (paper and pencil or electronic version; assisted by health professional or completed by patient alone, etc.) and how to interpret them. It is solid useful knowledge indispensable if dealing with tinnitus patients.

For many tinnitus patients, stress relief is an effective way to minimise their suffering. The chapter Stress-Related Tinnitus Treatment Protocols (8) contains a practical approach in the form of ready-to-use clinical procedures that have been designed to do just that – diminish tension caused by emotional stress. Such protocols may be of help to those healthcare professionals who cannot directly collaborate with psychologists. In addition, psychologists who are new to the field of tinnitus may also appreciate them.

An elementary point in measuring the success of therapy for tinnitus is a precise definition of the target of treatment and the ways it should be measured. The chapter Outcome Measures Associated with Perceived Stress (9) introduces this problem in detail, concentrating on perceived stress as a target for treatment and outcome measure. Healthcare practitioners and the leaders of future clinical trials should definitely be acquainted with this important part of knowledge about tinnitus. For a patient it is also important to know that their attending health professional has chosen the best means for diagnosis and treatment.

Concluding remarks

The more research we perform, the more knowledge we gain and this knowledge can then be used to explore new avenues for the diagnosis, treatment and for the monitoring of tinnitus. The best would be of course, to wipe out tinnitus of the surface of the Earth – we all know that. However, before that happens, we will keep calm and carry on our research from which, we hope, millions of patients suffering with tinnitus will benefit in the near future.

References

[1] Szczepek AJ and Mazurek B. Introduction. In: Szczepek A and Mazurek B, [eds]. Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 1-6.


[2] de Kloet ER and Szczepek AJ. Stress and glucocorticoid action in the brain and ear: implications for tinnitus. In: Szczepek A and Mazurek B. [eds]. Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 7-35.


[3] Hébert S, Mazurek B and Szczepek AJ. Stress-related psychological disorders and tinnitus. In: Szczepek A and Mazurek B, [eds.] Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 37-51.


[4] Cederroth CR, Basinou V, Park J-S, and Canlon B. Circadian influences on the auditory system. In: Szczepek A and Mazurek B, [eds.] Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 53-76.


[5] Eggermont JJ. Animal models of stress and tinnitus. In: Szczepek A and Mazurek B, [eds.] Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 77-94.


[6] Szczepek AJ and Mazurek B. Stress-related blood biomarkers. In: Szczepek A and Mazurek B, [eds.] Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 95-116.


[7] Brüggemann P and Rose M. Psychometric assessment of tinnitus patients within clinical practice settings. In: Szczepek A and Mazurek B, [eds.] Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 117-37.


[8] Cima RFF. Stress-related tinnitus treatment protocols. In: Szczepek A and Mazurek B, [eds.] Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 139-72.


[9] Hall DA. Outcome measures associated with perceived stress. In: Szczepek A and Mazurek B, [eds.] Tinnitus and Stress: An Interdisciplinary Companion for Healthcare Professionals. Cham: Springer International Publishing; 2017. pp 173-200.

About the author

Dr Agnieszka J. Szczepek 

Deputy Director

Research Laboratories of the ORL Department, Charité University Hospital Berlin


Visiting Professor

Faculty of Medicine, University of Zielona Góra

Agnieszka was born and raised in Warsaw, Poland, where she attended the University and graduated in Microbiology and Immunology in 1986. She fled from — at that time communist — Poland and immigrated to Canada, where in 1994 she commenced graduate studies at the Faculty of Medicine of the University of Alberta, Edmonton, Canada. In 1999, Agnieszka was granted the degree of Doctor of Philosophy in Medical Sciences.

Dr Szczepek joined the Research Laboratory of the Department of ORL, Charité University Hospital in Berlin in 2006, after a six-year appointment with the Max Planck Society in Berlin. Her research concentrates on biological aspects of hearing disorders. Of special scientific importance to her is the discovery of biomarkers for tinnitus diagnosis and monitoring. In 2017, she accepted an invitation to join the Faculty of Medicine in Zielona Góra as a Visiting Professor. In the same year, she obtained theWorld Hearing Center Award – Friends Forever.

Agnieszka teaches medical students in Germany and in Poland the pathologies of inner ear. She dedicates half of her teaching time educating future MDs about tinnitus.