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. 2022 Aug 24;31(4):1293–1298. doi: 10.1044/2022_AJA-21-00241

Treatment of Posttraumatic Stress Disorder Alleviates Tinnitus-Related Distress Among Veterans: A Pilot Study

John C Moring a,b,✉, Patricia A Resick c, Alan L Peterson a,b,d, Fatima T Husain e, Carlos Esquivel f,g, Stacey Young-McCaughan a,b, Elsa Granato f,g,h, Peter T Fox a,b; for the STRONG STAR Consortium
PMCID: PMC9907433  PMID: 36001823

Abstract

Purpose:

Military service personnel are at increased risk for developing tinnitus due to heightened exposure to acoustic trauma. The auditory disorder is the leading service-connected disability among veterans and is highly comorbidly diagnosed with posttraumatic stress disorder (PTSD). The biopsychosocial model illustrates that chronic health conditions are exacerbated or maintained by psychiatric distress. Therefore, alleviation of such psychiatric distress can have beneficial impacts on health conditions, such as tinnitus. The aim of this study was to determine whether individuals with both disorders who receive evidence-based therapy for PTSD will experience decreases in both PTSD and tinnitus-related distress.

Method:

Veterans with comorbid bothersome tinnitus and PTSD received cognitive processing therapy and were assessed for PTSD, tinnitus-related distress, and depression at baseline and 1 month posttreatment follow-up.

Results:

At posttreatment follow-up, participants demonstrated significant decreases in PTSD symptoms compared to their baseline scores. Participants also demonstrated decreased tinnitus-related distress and depression, with high effect sizes.

Conclusions:

This pilot study demonstrated that clinical management addressing psychiatric distress, as associated with PTSD, may simultaneously provide benefit for patients with bothersome tinnitus. Although not statistically significant due to the small sample size, large effect sizes indicate that tinnitus-related distress decreased as a function of receiving evidence-based therapy for PTSD. Future clinical trials should increase sample sizes and compare effects to control conditions.

Posttraumatic stress disorder (PTSD) is characterized as a psychological reaction to actual or threatened death, serious injury, or sexual violence (American Psychiatric Association, 2013). Over 90% of service members and veterans deployed post-9/11 have been exposed to at least one type of traumatic event during their deployments (Tanielian et al., 2008), and up to 32% of military service members and veterans have been diagnosed with PTSD (Gaylord et al., 2008; Hoge et al., 2006), making it the fourth most common service-connected item on the VA benefits report (Department of VA, 2019). One common comorbid disorder with PTSD is tinnitus.

Tinnitus is defined as a phantom auditory perception, in one or both ears, without an objective noise source (Hazell & Jastreboff, 1990). Types of tinnitus percept include ringing, buzzing, or a rushing sound; the intensity, frequency, and duration of these percepts vary among individuals (Unterrainer et al., 2003). Tinnitus also includes the associated distress, including the cognitive, emotional, and behavioral symptomatic sequalae (Husain, 2021).

Military personnel are at greater risk to develop tinnitus than the general population due to more frequent exposure to acoustic trauma associated with weaponry and large vehicles (Beach et al., 2013; Moring et al., 2018; Smalt et al., 2017). Exposure to acoustic trauma increases the likelihood of developing tinnitus before, during, and after deployment (Yurgil et al., 2016). Although the defining symptoms of tinnitus and PTSD are distinct, their prevalence rates and overlapping symptoms and effects indicate a possible connection between the two disorders.

Tinnitus-related distress and PTSD may reflect common sources and/or symptoms. It is possible that the event or source of PTSD symptomatology may be the same event that precipitated tinnitus, such as an assault causing head injury or exposure to an improvised explosive device. In such cases, a bidirectional relationship can exist between unwanted memories of the traumatic experience (Criterion B of PTSD) and tinnitus-related distress (Hinton et al., 2006). Avoidance of memories, thoughts, or feelings related to traumatic experiences, as well as avoiding external reminders of the trauma, are both symptoms of PTSD (Criterion C) and may exacerbate PTSD symptoms through mutual reinforcement. One study of veteran records indicated that individuals with both PTSD and tinnitus were more likely than patients without PTSD to report higher levels of self-assessed tinnitus handicap and sound-tolerance problems (Fagelson, 2007), causing avoidance of sound-enriched environments. Authors propose a mutually reinforcing mechanism between PTSD and tinnitus, in which individuals may avoid the stress related to both conditions. The same study that examined Cambodian refugees (Hinton et al., 2006) also demonstrated that tinnitus-related catastrophic thinking was related to PTSD severity. The tinnitus catastrophic thoughts were related to fear regarding the progression of tinnitus and physical health (e.g., deafness, heart weakness, fatal bodily weakness), which overlaps with PTSD Criterion D: negative alterations in cognition and mood. Individuals with PTSD often demonstrate catastrophic and exaggerated negative beliefs, including strong negative beliefs about themselves and strong negative feelings, such as fear. Finally, hyperarousal (Criterion E of PTSD) includes symptoms of irritability, difficulty concentrating, and sleep-related problems, all of which have been well documented among individuals with tinnitus (e.g., Henry et al., 2016). Other Criterion E symptoms, such as alertness and startle response co-occur with tinnitus and sound tolerance issues, affirming the potential for bidirectionality between the two disorders (Fagelson & Smith, 2016). The latest study demonstrated that many aspects of functioning that are impaired due to tinnitus are correlated with PTSD-related symptom clusters (Moring et al., 2022).

The biopsychosocial model (Andrasik et al., 2015; Engel, 1980) incorporates behaviors, emotions, cognitions, cultural values, social support, and socioeconomic status as biomedical factors to more fully understand the interactions between psychological distress and health-related issues, such as tinnitus. It is reasonable to consider that evidence-based therapies for one of these conditions (e.g., PTSD) may serve to alleviate the other (e.g., tinnitus).

Cognitive processing therapy (Resick, Monson, & Chard, 2017) is one such evidence-based psychotherapy for PTSD. Studies have demonstrated that CPT is efficacious among military service personnel and veterans (Kaysen et al., 2014; Monson et al., 2006; Morland et al., 2014; Resick, Wachen, et al., 2017; Resick et al., 2015). Patients learn how to develop more realistic thoughts, accept the traumatic event, and experience natural emotions associated with the trauma.

Based on the reasoning of the biopsychosocial model and prior research, we expected that negative emotional, cognitive, and behavioral states associated with PTSD served to exacerbate tinnitus-related distress. Therefore, it was hypothesized that from baseline to 1 month posttreatment follow-up, individuals with PTSD and bothersome tinnitus who received CPT would experience decreased PTSD symptoms as well as decreased tinnitus-related distress.

Method

Participants

Informed consent was obtained from all individual participants included in the study. Participants were U.S. veterans, 18 years of age or older who sought treatment for PTSD. Inclusion criteria required the experience of a Criterion A trauma defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013), a diagnosis of PTSD from an independent evaluator using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013), and self-reported bothersome tinnitus, operationalized as a score of 34 or higher on the Tinnitus Functional Index (TFI; Henry et al., 2016).

This study was reviewed by the University of Texas Health Science Center at San Antonio Institutional Review Board (Protocol #HSC20180524H). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institution and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For each session and evaluation, adverse events were monitored using an AE-monitoring form used in previous studies (Peterson et al., 2013).

Measures

CAPS-5

The CAPS-5 (Weathers, Blake, et al., 2013) is a semistructured interview that measures the DSM-5 (American Psychiatric Association, 2013) symptoms of PTSD; to reach diagnostic threshold, this scale requires the presence of at least one intrusion symptom, one avoidance symptom, two cognition or mood symptoms, and two arousal symptoms for a period of 1 month or more.

Patient Health Questionnaire–9

The Patient Health Questionnaire–9 (PHQ-9; Kroenke et al., 2001) is a nine-item self-report measure that measures the severity of affective and somatic symptoms related to depression and depressive disorders. The PHQ-9 has high internal consistency and correlates strongly with other measures of depression.

TFI

The TFI (Meikle et al., 2012) is used specifically for clinical trials in which tinnitus-associated symptom severity may change over time. Subscales include intrusiveness of tinnitus, sense of control, cognitive interference, sleep disturbance, auditory issues, relaxation issues, quality of life, and emotional distress. Reductions of approximately 14 points on the TFI represent clinically meaningful change (Meikle et al., 2012).

PTSD Checklist for DSM-5

The PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, et al., 2013) has excellent psychometric characteristics for screening and as a secondary indicator of PTSD symptom severity (McDonald & Calhoun, 2010).

Hearing Loss

Audiometric assessments to assess for hearing loss were not included as procedures of the study. However, a finger rub test was conducted during the psychosocial interview session, prior to the start of CPT. The finger rub test is a common screening test performed by neurologists that consists of rubbing the thumb and index finger 6 in. away from each ear. Participants who can hear the rubbing noise screen negative for severe hearing loss.

Procedures

Participants were recruited from advertisements on social media and by direct referrals from Department of Veterans Affairs (VA) providers. All participants met criteria for PTSD and tinnitus during baseline assessment conducted by an independent evaluator. Baseline measures of PTSD (CAPS-5), depression (PHQ-9), and tinnitus-related distress (TFI) were gathered.

If participants were found eligible and provided consent, they met with the study therapist prior to beginning CPT for psychosocial information and to discuss treatment goals. Throughout CPT, participants completed the PCL-5 (even numbered sessions) and the PHQ-9 and TFI (odd numbered sessions). Sessions 8–12 of CPT focus on erroneous thoughts based on current-day stressors in the themes of safety, trust, power and control, esteem, and intimacy (Resick, Monson, & Chard, 2017). During these sessions, participants were allowed up to 20 min of one session to devote to any tinnitus-related dysfunctional thoughts (e.g., “I cannot stand my tinnitus” or “There is something seriously wrong with me”). Upon completion of CPT, participants were scheduled for a 1-month follow-up to assess for PTSD, depression, and tinnitus-related distress. Throughout treatment prior to each assessment and intervention, adverse events, either related or unrelated to the study, were recorded. Adverse events can include any changes related to physical, emotional, and behavioral well-being, including the need for intervention outside of the trial. Based on these data, no participant in the study was fitted for hearing aids throughout their participation, nor did any participants indicate any changes in hearing. Based on the psychosocial intake, one participant used hearing aids in both ears, prior to the start of the trial.

Data Analytic Strategy

Primary variables of interest to this study included change scores of the CAPS-5, PHQ-9, and TFI, from baseline to posttreatment. Multiple t tests were conducted with Bonferroni correction for multiple comparisons. Alpha level for significance, with three tests, was set at α = .017.

Results

Participants were 10 veterans diagnosed with PTSD and bothersome tinnitus. Table 1 shows participants' demographic information. All participants screened negative for significant hearing loss, based on the finger rub test. The mean age of participants was 45.3 years, with an average of 15.74 years of service in the military. One participant (10%) dropped out of the study after Session 4 of CPT, and one participant did not complete posttreatment assessments.

Table 1.

Demographic characteristics.

Characteristic Total sample (N = 10)
Age 45.3 (SD = 9.75)
Male 9 (90%)
Married 7 (70%)
Ethnicity
 Hispanic 4 (40%)
 Caucasian/non-Hispanic 4 (40%)
 African American 2 (20%)
Education
 Associates degree 2 (20%)
 College/graduate degree 8 (80%)
Branch
 Army 8 (80%)
 Airforce 1 (10%)
 Marines 1 (10%)
Enlisted rank 9 (90%)
Months in military 188.9 (SD = 105.75)
Typical duty
 Combat arms 5 (50%)
 Combat support 2 (20%)
 Combat service support 3 (30%)
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Multiple t tests, with Bonferroni corrections for multiple comparisons, showed significant decreased symptoms of PTSD as measured by the CAPS-5 from pretreatment (M = 33.13, SD = 8.08) to posttreatment (M = 16.13, SD = 14.45), t(1, 7) = 3.42, p = .01, d = 1.29. Decreases in depression from pretreatment (M = 14.10, SD = 6.59) to posttreatment (M = 7.38, SD = 4.98), t(1, 7) = 2.68, p = .031, d = 1.01, and tinnitus-related distress from pretreatment (M = 65.16, SD = 15.97) to posttreatment (M = 41.95, SD = 24.42), t(1, 7) = 2.56, p = .038, d = 0.97, approached significance. Figure 1 shows pre- and posttreatment scores. Figure 2 shows session-by-session mean PCL-5, PHQ-9, and TFI scores. The mean change on the TFI was M = 22.34 (SD = 24.71), and half (n = 4) of the participants experienced a clinically meaningful change on the TFI, with reductions greater than 14 points (Meikle et al., 2012).

Figure 1.

Figure 1.

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Pre- and posttreatment scores of the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (CAPS-5), Tinnitus Functional Index (TFI), and Patient Health Questionnaire–9 (PHQ-9).

Figure 2.

Figure 2.

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Session-by-session scores of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), Tinnitus Functional Index (TFI), and Patient Health Questionnaire–9 (PHQ-9).

Discussion

Results of this study showed that at a 1-month posttreatment follow-up, participants with comorbid tinnitus and PTSD who completed CPT experienced significant reductions in their PTSD symptoms, with a large effect size. Though not statistically significant, participants also experienced decreases in symptoms of depression and tinnitus-related distress, with large effect sizes. Large effect sizes indicate the likelihood of a statistically significant reduction in tinnitus-related distress as a function of the treatment of PTSD, in the context of a larger sample size. This study demonstrated promising results for the possible alleviation of tinnitus through evidence-based psychotherapy for PTSD among patients who experience both tinnitus and PTSD.

Limitations of this pilot study include its small sample size, which reduced its statistical power and limited the significance of pre- to posttreatment changes in depression and tinnitus-related distress. Other limitations of the study include the lack of audiometric evaluation to characterize participants' auditory function more fully as it relates to tinnitus. Future studies should include larger participant sets and more detailed evaluation of tinnitus and hearing status; a randomized clinical trial to include and compare other treatments would be informative.

In summary, the hypotheses for this study were partially supported. Treating the primary psychiatric distress related to PTSD led to attenuation of their tinnitus-related distress, though this change did not reach statistical significance. Future, larger studies should examine approaches to more specifically tailor psychotherapy, compare alternative treatment strategies, or develop innovative neuromodulatory therapies.

Author Contributions

John C. Moring: Conceptualization (Lead), Data curation (Lead), Formal analysis (Lead), Funding acquisition (Lead), Investigation (Lead), Methodology (Lead), Project administration (Lead), Resources (Lead), Writing – original draft (Lead), Writing – review & editing (Lead). Patricia A. Resick: Conceptualization (Equal), Funding acquisition (Supporting), Investigation (Supporting), Methodology (Equal), Writing – original draft (Supporting), Writing – review & editing (Supporting). Alan L. Peterson: Funding acquisition (Supporting), Methodology (Supporting), Resources (Equal), Writing – original draft (Supporting), Writing – review & editing (Supporting). Fatima T. Husain: Funding acquisition (Supporting), Methodology (Equal), Writing – original draft (Equal), Writing – review & editing (Equal). Carlos Esquivel: Conceptualization (Supporting), Funding acquisition (Supporting), Resources (Supporting). Stacey Young-McCaughan: Methodology (Supporting), Resources (Supporting). Elsa Granato: Conceptualization (Supporting), Methodology (Supporting). Peter T. Fox: Conceptualization (Equal), Funding acquisition (Equal), Writing – original draft (Supporting), Writing – review & editing (Supporting).

Trial Registration

ClinicalTrials.gov. NCT03702166. Registered October 10, 2018, https://clinicaltrials.gov/ct2/show/NCT03702166?cond=tinnitus&cntry=US&state=US%3ATX&city=San+Antonio&draw=1&rank=1

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, J.C.M., upon reasonable request.

Acknowledgments

The project described was supported by the National Center for Advancing Translational Sciences, through the Clinical and Translational Science Award KL2 TR002646. The content is solely the responsibility of the authors and does not necessarily represent an endorsement by or the official views of the National Institutes of Health, the U.S. Air Force, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government. The authors would like to thank Amanda Flores, Antoinette Brundige, and Deanne Hargita for administrative support.

Funding Statement

The project described was supported by the National Center for Advancing Translational Sciences, through the Clinical and Translational Science Award KL2 TR002646. The content is solely the responsibility of the authors and does not necessarily represent an endorsement by or the official views of the National Institutes of Health, the U.S. Air Force, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government. The authors would like to thank Amanda Flores, Antoinette Brundige, and Deanne Hargita for administrative support.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, J.C.M., upon reasonable request.

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