The Cognitive Behavioral Approach

Several so-called “cognitive behavioral” accounts for tinnitus have been postulated (Cima et al. 2011a; Hallam et al. 1984; Kleinstauber et al. 2012; McKenna et al.

2014). A promising one is based on a fear-avoidance model (FA model) of chronic pain (Vlaeyen and Linton 2000, 2012), since in this model, predictions about the behavioral components in the maintenance of tinnitus distress are included. The FA model (Fig. 8.3) for chronic tinnitus offers explanatory predictions about both the

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Fig. 8.3 The fear-avoidance model cognitive processes and the behavioral mechanisms. It predicts that individuals perceiving the tinnitus signal are subject to automatic emotional and sympathetic responses. These symptoms are misinterpreted as harmful or threatening. If the signal persists, the coinciding threatening (alarm) states, which indicate malignance of the signal, elicit conditioned, both classical and operant, fear responses, i.e., fear, increased attention, and safety seeking, i.e., avoidance and escape behaviors. These safety behaviors become negatively reinforced through instant decreased fear, which is adaptive in the acute phase. In other words, by avoiding, or not exposing themselves to tinnitus-related perceptions, patients learn that their fear instantly diminishes. However, in the long run, through persistent avoidance of tinnitus percept as well as tinnitus-eliciting or tinnitus-increasing stimuli, the heightened fear and fear responses, such as hypervigilance and safety seeking, are maintained. Avoidance behaviors subsequently lead to task interference and functional disability (Blaesing and Kroener-Herwig 2012; Hesser et al. 2009). The maintained high threat value of the tinnitus leads to increased tinnitus severity and distress, feeding into an endless circle of increased disability (Cima et al. 2011b).

The cognitive behavioral model predicts that the tinnitus signal invokes automatic sympathetic and emotional responses, which are misinterpreted as harmful or threatening, leading to safety behaviors.

A typical feature of the FA model is its prediction; next to the maladaptive pathway (leftward), an alternative and more adaptive pathway (turning right) is proposed, whereby a positive or neutral evaluation of the tinnitus results in no or low fear of the tinnitus and in partially or completely decreased distress. In other words, the tinnitus sound is accepted by the system as being benign; therefore, no unwanted attentional resources are needed. In turn, avoidance and/or escape behaviors do not interfere with daily tasks, resulting in lack of severe disability due to tinnitus.

Accumulating evidence indicates that a cognitive behavioral treatment, based on this fear-avoidance notion, which targets reappraisal of and exposure to the tinnitus sound, significantly reduces tinnitus distress as well as tinnitus suffering and improves the quality of life and daily functioning of tinnitus patients (Andersson 2002; Andersson and Lyttkens 1999; Andersson et al. 2002; Cima et al. 2012; H. Hesser et al. 2011; Hoare et al. 2011; Martinez-Devesa et al. 2010). However, the cause-effect relationships of specific learning mechanisms are still unknown (Cima et al. 2011a; J. A. Henry et al. 2005a; Kleinstauber et al. 2012).