The document discusses the clinical management of catastrophic tinnitus. It notes that current articles on tinnitus management do not adequately address catastrophic cases, which present more like a medical emergency. It argues for a multidisciplinary expert team approach to manage these severe cases, including the judicious use of medications. It also discusses the difficulties in researching tinnitus due to its heterogeneous nature and subjective experience.

1. Tinnitus Talk March 2014 www.tinnitus.asn.au Page 1 ABN 38 529 817 275 • VOL 33 • No. 1 • March 2014 A self-portrait of Goya being attended to by his doctor, 1820. (Wikimedia Commons) In 1713, Italian physician Bernardinus Ramazzini described in his De Morbis Artificum Diatriba a mysterious set of symptoms he was noticing among artists, "The business of a Painter or Varnisher is generally, and not without reason, considered an unhealthy one. Of the many painters I have known, almost all I found unhealthy. If we search for the cause of the cachectic and colourless appearance of the painters, as well as the melancholy feelings that they are so often victims of, we should look no further than the harmful nature of the pigments…” He was one of the first to make the connection between paint and artists' health, but it would take centuries for painters to switch to less-harmful materials, even as medicine gradually clued into the bodily havoc “saturnism” could wreak. In 1834 London Medical and Surgical Journal describes sharp stomach pains occurring in patients with no other evidence of intestinal disease, thus leading the authors to suspect that this “painter’s colic” was a “nervous affection” of the intestines that occurs when lead “is absorbed into the system.” Paints weren’t the only source of lead overdose in past centuries, though. Through the 1500s, lead was a common sweetener in wine, in the form of “litharge,” causing periodic outbreaks of intestinal distress throughout Europe. Occasionally, lead was even used as a medicine; the 11th-century Persian physician Avicenna’s Canon mentioned its usefulness in treating diarrohea. In the Middle Ages, lead could be found in makeup, chastity belts and spermicides. Though typesetters, tinkers, and drinkers of lead-poisoned wine fell victim to saturnism, the disease was perhaps most widespread among those who worked with paint. The symptoms of this “colic” ranged, but they often included a “cadaverous-looking” pallor, tooth loss, fatigue, painful stomach aches, partial paralysis, and gout, a build-up of uric acid that causes arthritis—all of which resemble the symptoms of chronic lead poisoning seen today. In fact, the ailments that many renowned artists experienced didn’t just prompt their gloomy

2. Page 2 www.tinnitus.asn.au Tinnitus Talk March 2014 works – they might have been caused by them, too. Lead poisoning among historical figures is famously difficult to prove, in part because the condition was not known or recognized in most of their lifetimes. We can’t know whether the delusions, depression, and gout many Renaissance masters experienced can be attributed to their paint or just their physiologies. Julio Montes-Santiago, an internist in Vigo, Spain, recently evaluated the existing evidence of lead poisoning among artists across five centuries for a new paper in Progress in Brain Research. Based on the available descriptions of their materials and symptoms, history’s most famous sufferers of lead poisoning, he argues, likely included Michelangelo Buonarroti, Francisco Goya, Candido Portinari and possibly Vincent Van Gogh. Many art historians think Van Gogh might have suffered from epilepsy and bipolar disorder, but Montes-Santiago argues that lead poisoning likely contributed to his delusions and hallu- cinations. The artist was known to have sucked on his brushes, possibly because lead has a sweet aftertaste. Meanwhile, other scholars have disputed the lead poisoning hypothesis, arguing that the root of Van Gogh’s distress was porphyria, malnutrition, and absinthe abuse. Goya occasionally applied his paints directly to canvas with his fingers, which Montes-Santiago Michelangelo in The School of Athens, 1509. (Wikimedia Commons) argues is one reason he experienced problems like tinnitus and vertigo, trembling hands, weakness of the limbs and blindness. In his famous 1820 self-portrait, Goya painted himself being embraced by his doctor. Musicians Beethoven and Handel also might have been afflicted with saturnism, but not because of the nature of their craft. Samples of Beethoven’s hair examined by the Pfeiffer Research Centre in Illinois showed high lead concentrations, possibly as a result of the “high content of lead in the Hungarian wines that the musician drank, the repeated biting of his lead pencils, and lead-rich medicines prescribed by his doctor,” Montes-Santiago notes. "Discovery of the Land" by Portinari, 1941 (Wikimedia commons) Most of the earlier artists may not have known about the connection between their materials and their health, Portinari certainly must have. By the mid-1800s, the health impacts of lead had become clear. An 1836 book notes, for example, “The business of a Painter or Varnisher is generally, and not without reason, considered an unhealthy one. Many of the substances which he is necessarily in the habit of employing are of a nature to do injury both to the nerves and the inside.” According to Montes-Santiago, though, Portinari seemed to strongly prefer working with the lead paints, reportedly saying “They forbid me to live,” about the doctors who urged him to give them up. “Sometimes, art hurts,” Montes-Santiago writes. “But it also can save.”

3. Tinnitus Talk March 2014 www.tinnitus.asn.au Page 3THIS ISSUECLINICAL MANAGEMENT OF ‘CATASTROPHIC TINNITUS’ Dr Brendan T. O’Sullivan, PhD MA MB BS BSc (Hons1) FRANZCP Consultant Psychiatrist Recent articles published about Tinnitus and its Clinical Management in the prestigious journal The Lancet by Langguth et al (September 2013) and Baguley et al (November 2013) deserves a response for the benefit of the public who suffer with tinnitus.Both papers have their strengths and weaknesses, but, in this author’s view, both articles are not representative of actual medical or clinical specialist practice, especially in the most severe and so-called ‘Catastrophic’ cases of tinnitus. Such Catastrophic cases present more like a medical and psychiatric ‘emergency’, rather than the chronic conditions reviewed by the above authors. Quite clearly, in these ‘medical emergency’ cases, most “talk therapies”, “learn to live with it” assurances, “cognitivere-training” and “relaxation techniques” are a total failure at that time. ‘Models of Care’ for catastrophic tinnitus sufferers: There are both good and bad ‘Models of Care’ for catastrophic tinnitus sufferers. In my own experience as a Clinical Psychiatrist and with over 25 years of active interest in this vexed area of tinnitus management, there is a dearth of studies (or none at all) which deal specifically with the management of acute-onset ‘Severe’ to ‘Catastrophic’ categories of tinnitus. This is a serious issue as the use of ineffective treatments at this early stage and/or the use of glib or negative statements by doctors about the poor prognosis of tinnitus and/or the stated absence of any role for medications and other therapies, simply adds to the distress and sense of hopelessness felt by the tinnitus patient. Undue pessimism and negativity and the use of ineffective or sub-optimal treatments strategies at an early stage may lead to ‘iatrogenic’ (doctor- induced) exacerbations in the tinnitus experience as well as to long-term chronicity. It also deprives the patient of ‘best-practice’ treatments that are available. Many people with tinnitus present with acute anxiety and depression - which go hand in hand with ‘Catastrophic Tinnitus’. Most have received ineffectual treatments and/or negative prognostic comments which have caused them to medically misconceive and to internally ‘catastrophise’their situations well beyond the facts. The first step is therefore to attempt to ‘undo’ this unnecessary early damage. Whilst not everyone will claim to be an expert in this field, the medical dictumshould always remain “Above all, do no harm”. Undue pessimism and suboptimal treatments are harmful. If the medical practitioner is not conversant or comfortable with managing this problem, then prompt ‘referral’ to someone or to some ‘expert group’ used to dealing with these matters is the best of all possible outcomes. Far too many people with tinnitus end up in the suburbs with their General Practitioner in a ‘folly’ of mutual hopeless- Tinnitus & Lead in Paint 1-2Clinical Management of ‘Catastrophic’ Tinnitus 3-8Research 9-10Editorial 11Directory 12WE ARE COUNTING ON YOU TO SUPPORT OUR ANNUAL APPEAL! PLEASE USE THE ENVELOPE SENT WITH DEC. TINNITUS TALK. BUY YOUR RAFFLE TICKETS TO WIN GREAT PRIZES! ness and helplessness. In my opinion, an ‘expert group’ as referred to above, would ideally be a ‘multi-disciplinary team’ which brings together all of the requisite skills (possessed by no individual alone) and which can advise or act assertively, actively and confidently in all cases presented, especially in the most severe of cases. In my past experience this definitely includes the judicious and expert use of medications in the acutely severe and ‘catastrophic’ cases. Such a tinnitus ‘expert opinion group’ could be quite similar in constitution to a standard ‘Chronic Pain Clinic’ now functioning in many large teaching hospitals across Australia. It is necessarily ‘multidisciplinary’ as no single discipline will be able to meet all of the needs of a tinnitus sufferer. It should consist of an otolaryngologist (Ear, Nose & Throat surgeon – with a capacity for dental referral); a Psychologist competent in cognitive behaviour and tinnitus retraining methods (with capacity for social work referral; a Psychiatrist for the

4. Page 4 www.tinnitus.asn.au Tinnitus Talk March 2014CLINICAL MANAGEMENT OF ‘CATASTROPHIC TINNITUS’ cont/… more complex cases or for those in whom psychoactive medications are considered (such as in depressed, acute or ‘catastrophic’ cases), an Audiologist who has the technical skills necessary to optimise hearing and masking options and finally a lay person, preferably a fellow tinnitus sufferer who can assist with education and in connecting the tinnitus sufferer to various appropriate and positive supports. This proposed group could meet physically or via tele-health video connection at agreed times and as necessary, thus covering both urban and regional needs. The multidisciplinary group may be active in both assessment and treatment of individuals referred to it, and in providing ‘advisory’ functions to other General Practitioners and professionals seeking advice and support in the management of their own tinnitus patients. A multidisciplinary group cannot of course be ‘all things to all people’ and, in the end, each patient must be assessed ‘individually’ and comprehensively in relation to their own individual needs. A ‘one-size-fits-all’ approach will never work with tinnitus, mainly due to the enormous heterogeneity [differing in nature] of the disorder as well as the variability of responses that different people have to the disorder. So what exactly is the scope of this problem? And why has it been so difficult to study tinnitus in the past in order to find clear evidence-based and cost- effective treatments. Why is it so difficult even now to devise and implement a model of optimal ‘best- practice’ care such as that suggested above? The relatively high incidence of tinnitus and why it is so difficult to study: Whilst up to a ‘third’ of all Australian adults will experience tinnitus at some time during their lives (usually only transiently), only 10-15% of these sufferers a small but significant number fall into the ‘Very Severe’ or ‘Catastrophic’ categories. These people may end up being referred for medical specialist treatment and/or may even require hospitalisation (medical or psychiatric). A tinnitus patient is not ‘crazy’, but the disorder is notorious for challenging the coping mechanism of even the sanest individual and tinnitus is very highly correlated with clinical anxiety and depression. This paper concerns the latter – the most ‘severe’ or ‘catastrophic’ cases where appropriate medications and/or hospitalisation is critically important in order to provide temporary (but certain) relief, and also to allow sufficient time for the patient to be properly evaluated for all possible medically-reversible causes of tinnitus and for appropriate treatments to be commenced. Medically reversible and treatable ‘causes must not be missed in any circumstances. Causes may vary from the trivial (ear wax), through to trauma (with high frequency hearing loss), through to Meniere’s disease and tumours. In the above- mentioned Lancet papers, medications were generally ruled out as being “ineffective” and as having “no evidence to support their use”. Whilst this may be true for many mild-moderate chronic sufferers (and that point too may be disputed), it is certainly not true for the acute and severe or ‘catastrophic’ presentations. Some particularly illustrative examples are given below in the Case Studies. There is no disagreement that the value of medications and other treatments in mild-moderate cases of chronic tinnitus is limited within those patients as a group. However, there are certain individuals and certain individual ‘treatments’ and remedies (which are well laboriously reviewed elsewhere), which are of great value to that individual patient. This is not yet a perfect science. If these particular agents appear to work for the individual and if there are no contra-indication to their use, then this author’s view is that they should not be discouraged. If a therapy appears to work for the patient, then it does work (for that patient). Whilst the power of placebo is well known, there is still a lot that is not yet known or understood about tinnitus, its aetiology [study of the causes or origination] or all of its treatment possibilities. The hazard, of course, is going on a never-ending ‘search’ for the ‘miracle cure’ and, out of desperation, falling prey to expensive rorts and misinformation. Even whole organisations have been hijacked in the past by this sort of activity by big Pharma and by other vested interests. Many tinnitus sufferers fall into the ‘severe’ category because they have a ‘co-morbidity’ such as hearing loss or other medical illness or they have significant anxiety and depression to a significant clinical degree. Each individual case should therefore be assessed as an ‘individual’ person. There are probably as many types of tinnitus and the experience of tinnitus as there are people who have it! Co-morbid medical and psychiatric disorders are often missed or ‘buried’ under the dominant distressing symptom, namely the tinnitus. Everyone’s attention is so focused upon the tinnitus so that other things are easily missed. Some diagnoses, like untreated anxiety and depression, actively contribute to a further increased perception of tinnitus. It’s the proverbial ‘vicious cycle’. Anxiety and depression fuel tinnitus, and the tinnitus experience fuels anxiety and depression. This phenomenon moves what would have been ‘mild-moderately severe’ tinnitus, into the severe or even catastrophic range.

5. Tinnitus Talk March 2014 www.tinnitus.asn.au Page 5CLINICAL MANAGEMENT OF ‘CATASTROPHIC TINNITUS’ cont/… Scientific literature reviews of tinnitus and its management usually concern chronic mild- moderate tinnitus and ‘uncomplicated’ tinnitus, but none of these studies deal specifically with the acute medical emergency-type presentation or ‘catastrophic’ presentation. It is, of course very difficult to make a study of this severe or catastrophic group, since every effort goes into managing their acute medical needs, and the prospect of a ‘placebo-controlled’ or ‘observer- blinded’ trial would be unethical. Review articles of the various treatments for chronic tinnitus usually rule out long-term medication options (see References below). Such reviews (including meta- analytic reviews of multiple studies) are characterised by ‘pooling’ the data from many individuals with many different tinnitus pathologies and tinnitus treatments and ‘pooling’ studies with completely incomparable methodologies. In these circumstances, whilst the actual number of patients reviewed may be sizable, it is impossible to obtain any ‘statistically significant findings’. Such results, if they existed, are simply lost in the ‘statistical noise’. This is because tinnitus patients are so heterogeneous, encompassing such an enormous range of pathologies and a wide range of non-standardised treatments (i.e. in statistical terms, there is a wide ‘standard error’). This makes systematic scientific studies very difficult indeed to perform on anything other than small cohorts or groups of subjects. Sub-categorisation of tinnitus may allow a more sophisticated and refined and controlled approach to tinnitus research in the future. Tinnitus is of course a ‘symptom’, not a ‘disease’, and the causes of tinnitus and the responses to its various treatments are so very varied and so very wide that it is probably one of the most ‘heterogeneous’ populations of all to study medically. To perhaps labour this point, there are simply too many variables in a tinnitus population and, in addition, very few of these variables can be ‘controlled for’ in a usual medical research manner. Finally, the experience of tinnitus is so very subjective and is not readily amenable to external independent and objective measurement. A similar situation to this exists in acute and chronic ‘pain’ research which ‘pain’ being a highly subjective and emotionally-laden experience – although that has not stopped major progress in this particular area over the past 25 years! Conclusions about diagnosis and treatment of patients from meta-analytic reviews which ‘lump together’ and ‘pool’ many patients and many quite methodologically different studies, are, in the end, simply a ‘pool of confusion’. It is thus very difficult in these circumstances to end up with clinically relevant ‘conclusions’, or with any clear or credible ‘recommendations’ from this sort of analysis (see Reference below including “Review Articles – Tinnitus – The Cochrane Library”). All is not lost, however, as knowledge about tinnitus has still grown substantially and there are significantly more sophisticated studies now on foot. In the meantime we still have single ‘Case Reports’ of individual cases. These reports may also be criticised as being simply ‘anecdotal’ and not representative of or applicable to the wider group. Case reports are also not amenable to any proper statistical evaluation (not with a sample size of only one!). Yet, as every medical practitioner knows, there is still an ‘Art’ in the ‘Science’ of Medicine, and useful recommendations can be made from individual case studies. These findings may be cautiously and judiciously extrapolated to other similar cases. I believe that this is especially true in the most severe ‘medical emergency’ or ‘catastrophic’ presentations of tinnitus. Defining the population: Just how severe is ‘catastrophic’? The short answer is that tinnitus is ‘catastrophic’ when it is so acute in its onset, and/or so severe in its intensity, that it results in extreme distress which significantly or entirely disrupts the sufferer’s social and occupational functioning and general health. There is, as mentioned above, a very strong link observed between tinnitus and the development of mental disability or disorder, particularly anxiety, panic attacks and clinical depression (often calledMajor Depression). The specific symptoms of Major Depression are well defined and readily accessible in websites such as ‘Beyond Blue’ and ‘Black Dog’. The strength and the mechanism of this linkage between tinnitus and Major Depression is not well understood, but it is a very common observation. This ‘dual’ diagnosis of depression and tinnitus sets up an apparent positive feed-back loop with the experience of tinnitus and depression both amplifying each other! This is the first group of ‘catastrophic’ tinnitus, and it is dangerous because it leads to additional chronic disability and, in some cases to self-harm. It also leads to extreme distress to other family members and to all other concerned individuals who watch on helplessly and who are often themselves included in the ‘collateral damage’ in these situations. It is not uncommon for the ‘spouse’ to present with depression!

6. Page 6 www.tinnitus.asn.au Tinnitus Talk March 2014 CLINICAL MANAGEMENT OF ‘CATASTROPHIC TINNITUS’ cont/… Major Depression is a very treatable illness and it must be identified and assertively treated with appropriate mediations and/or with other medical treatments in order to break this cycle. Further, Major Depression is in fact one of the most responsive of all medical conditions with appropriate modern medication. It is therefore, in my view, recklessly negligent for a doctor to miss this diagnosis and/or to fail to treat this condition and/or ‘under-treat’ this condition. The onset of tinnitus, like any major life event or disability, often ‘un-masks’ pre-morbid underlying psychopathology which had, up until that time, not been evident. Alternatively, tinnitus so taxes a normal person’s ‘normal’ coping mechanisms that ‘normal’ coping skills (which are appropriate and sufficient for most ‘normal’ life) are swamped and start to fail. Persistent tinnitus, like chronic pain, is an ‘ego-alien’ and highly ‘intrusive’ experience for which very few of us would be likely to have pre- existing coping skills. So this is the second group of potentially ‘catastrophic’ sufferers, those in whom normal coping mechanisms fail completely and often dramatically. There is an extremely strong ‘inter- play’ between tinnitus and pre-morbid personality and coping styles, and tinnitus in a severe form cannot be managed effectively by ‘talk’ or ‘tablets’ alone without a proper assessment. People with borderline or obsessive-compulsive personality traits seem to be especially vulnerablein situations where there is ‘loss of control’ or threatened loss of attachments, and secondary drug and alcohol abuse is quite common in tinnitus patients. Pre-morbid personality traits, depression and self-harm are well illustrated in ‘Case 1’ below. There may be strong personal and cultural determinants as well to these presentations, which is illustrated in ‘Case 2’ below. The third category of ‘catastrophic’ tinnitus is when it occurs as a co-morbid condition with another serious medical or psychiatric disorder. Tinnitus is frequently associated with hearing loss that is ‘acquired’ later in life, but it does infrequently occur in congenital deafness. This latter population provides similar challenges to tinnitus patients when they develop co-morbid mental disorders and ‘Case 3’ illustrates these difficulties and the need for active and assertive intervention. In summary, whilst these are single Case Study examples, they demonstrate many of the general principles and broader challenges involved in dealing with tinnitus patients who have ‘catastrophic’ presentations. Case Studies - Case 1 My very first exposure to a patient with severe ‘catastrophic’ tinnitus was itself a catastrophic and traumatic experience which is etched in my memory forever. As a young medical Registrar training in Psychiatry I was asked to evaluate a young man who self-presented to the Emergency Department of a large teaching hospital in Sydney with a pencil stuck deeply into his right ear. There was blood and other fluid draining out of that ear. The wound was self-inflicted. He succeeded in totally destroying his hearing in his right ear but the tinnitus remained. So what could possibly have made this 27 year old man act in such a hazardous and self-destructive manner? The answer was tinnitus. It was of a so-called ‘catastrophic’ severity. It emerged that his work involved hammering in hundreds of metal nails prior to floor sanding and his hobby was listening to loud music through earphones. There was a whole range of other matters in this young man’s life which also needed to be addressed over time. He had many obsessive-compulsive personality traits and was particularly averse to anything that threatened a loss of control over his life. He was a perfectionist. In fact it was now worse in both ears! This man required hospitalization for medical and psychiatric evaluation and acute treatment. This included acute sedation and relief from tinnitus using a combination of anti-psychotics (then chlorpromazine) and benzodiazepines (quite significant doses of clonazepam – which I have used often since then in other severe situations). The latter was then titrated down on a slow taper over a period of 4 weeks to avoid any rebound exacerbation of tinnitus. This allowed sufficient time for the otolaryngologist and neurosurgeon to assess and manage the damage, and also enough time for us to assess and educate the patient as to what was happening. It was also the beginning of a lasting therapeutic alliance which was central to his longer term management. None of this would have been possible without hospitalization and acute medical care including the use of significant doses of psycho-active medications in the short to mid-term. It emerged that there were a whole range of other matters in this young man’s life which also needed to be addressed over time. He had many obsessive-compulsive personality traits and was particularly averse to anything that threatened loss of control over his life. He was a perfectionist who had lost control and caused the most

7. Tinnitus Talk March 2014 www.tinnitus.asn.au Page 7CLINICAL MANAGEMENT OF ‘CATASTROPHIC TINNITUS’ cont/… appalling injury to himself in a highly dissociated and distressed state. He was later supported in obtaining worker’s compensation and, although he only has hearing in his left ear, he eventually accommodated to his tinnitus which, although still present, he describes as “manageable”. The therapeutic end-point here was not ‘cure’, but ‘manageability’. Case 2 This case is of a 12 year old indigenous child with chronic otitis media (middle ear infection). Otitis media is unfortunately still common in the indigenous community in Australia. Otitis media leads to acute or chronic hearing loss and therefore to a loss of educational and social opportunity. One of the major disadvantages in this population is a lack of access to usual medical and/or psychiatric services. The government’s public health awareness and its ‘closing the gap’ initiatives have definitely been a step in the right direction, but there is still a long way to go yet. Substance abuse (solvents etc.) and alcohol abuse from an early age is rife throughout the community and there is a total cultural and social breakdown in some areas. The presenting symptom for this 12 year child was tinnitus. This was soon followed by a number of behavioural disturbances. The boy described a constant noise in his head like ‘cicadas’. When the tinnitus became worse he could not get to sleep at all. Sleep deprivation seemed to add significantly to his problems. His behaviour at school then became a major issue. He could not concentrate at school because of the intrusive tinnitus and his school friends said that he was going “mad”. The boy did indeed believed that he was “cursed” in some way, and he asked for help from his extended family and from an Elder who offered him local remedies. These did not work. He said that “even my own people can’t fix me”. The primary anti-tinnitus treatment for this young Aboriginal fellow was of course ‘antibiotics’. He was also commenced on a slowly tapering dose of a longer-half-life benzodiazepine over a period of some 4-6 weeks. The culturally determined ‘meaning’ that he attributed to his tinnitus had been a major factor in making this a ‘Catastrophic’ presentation. The last report I had was that he is doing very well and has finally completed his schooling. Case 3 The Deaf community is a small but significant minority in the Australian and world community. Capital ‘D’ Deaf also means having a primary cultural and linguistic affinity with the broader deaf community. Australian Sign Language (AUSLAN) unites this population culturally and socially and is an important part of group identity. Some have congenital (from birth) or acquired (after birth) deafness and it is either partial or total (profound). Hearing loss from early in life (such as from meningitis or the effects of earlier antibiotics) interferes with the development of language (pre- lingual deafness). Some are born with deafness, with many in the past having had intra-uterine Rubella or intra-uterine Cytomegalovirus infections. Others have congenital (gene-related) family deafness which occurs with aunts, uncles, parents and children all being deaf. They are culturally ‘Deaf’ as well with their own language and do not necessarily welcome the advent of cochlear implantation. All in all, however, these are wonderful people with many prominent and productive citizens amongst them. They do suffer all the same rates of concomitant mental illness as all other members of the community, including up to a 20% life-time incidence of Major Depression and almost 1% with Schizophrenia. This is a sizable number of Australians who are not only Deaf or hearing-impaired but who also have a mental illness as well, either at some stage in their lives or for most of their adult lives. All other psychiatric disorders are also equally represented in the Deaf community. A 47 year old intelligent and well-respected middle aged Deaf-signing lady was referred to me by her GP. She had one single complaint only - a total conviction that she had “braincancer”. Unusual for a congenitally Deaf person, she heard ‘noises’ in her head which we believed to be typical of tinnitus. Further questioning also indicated that she felt excessively guilty over trivial matters and had major sleep and appetite disturbances. She thought she was a burden to her family. The overarching priority here was ‘patient safety’ and in providing the fastest pathway towards her recovery in hospital. We did have such a Deaf Psychiatric Unit modelled on the Preston, Lancashire UK Unit under the late Dr John Denmark, whom I had met and much admired. The Sydney Unit was opened in 1994 by the Hon Ron Phillips MP, NSW Minister for Health, himself the Child of Deaf Adults (a ’CODA’), but was later closed. Our Deaf-signing depressed lady rapidly improved in the Deaf Psychiatric Unit on standard anti- depressant medication. She no longer believed that

8. Page 8 www.tinnitus.asn.au Tinnitus Talk March 2014 CLINICAL MANAGEMENT OF ‘CATASTROPHIC TINNITUS’ cont/… she had cancer and her noises subsided. She did not know why she had been so worried and guilty and she rightly observed that her depression had been ‘tricking’ her ‘mind’. Conclusions: The above case histories indicate the diversity of patients and conditions that are associated with the ‘symptom’ of tinnitus. There are a very large number of medical diagnoses and diseases that can underlie the ‘symptom’ of tinnitus. They all must be considered by a duly qualified doctor or specialist. Any reversible medical causes must not be missed. Tinnitus does not occur separately from the person and personality who suffers from it. Sometimes normal coping mechanisms are over- loaded and fail, sometimes underlying vulner- abilities are exposed. Sometimes tinnitus occurs in the context of co-morbid illnesses which also must be identified and managed. Medications are useful and indeed necessary in the management of severe or catastrophic tinnitus, especially to settle the patient sufficiently for a more thorough medical examination to take place and to allow time for the commencement of appropriate treatments. Concomitant or co- morbid medical and psychiatric illnesses need to be identified and actively treated. Conditions such as middle ear infections and Meniere’s disease may respond quickly to present treatments. Certain medications such as benzodiazepines provide genuine and much- needed temporary relief from severe unremitting tinnitus, but should not be continued in the long term. A slow taper down period of 4-6 weeks seems to be effective in most cases. Some short half-life benzodiazepines are contra-indicated as they may cause multiple rebound episodes of anxiety and tinnitus during the day and also have significant addictive potential. Psychiatric care (or at least the use of psycho- active medications in competent medical hands) is most definitively required in cases of severe or catastrophic tinnitus. Anti-psychotic medications undoubtedly have a short-term role in severe or extreme presentations with the benefits of medication far outweighing any potential risks. A best-practice ‘Model of Care’ needs to be developed in Australia, starting with prevention and youth education about the perilous harm done by excessive noise exposure, but also including a supra-regional (State-wide) multi- disciplinary specialist response team to provide much needed integrated treatment plans for patients and to support and advise both patients and their treating doctor. ACKNOWLEDGMENTS In Australia the cause of tinnitus awareness and its treatment has been persistently and consistently supported by the Australian Tinnitus Association (ATA). I have enormous respect for all those staff members and other members who have given so much to this cause and this organisation over so many years. I also acknowledge the patients and sufferers of tinnitus who are, in the end, the best teachers of the medical profession. References: Tinnitus: causes and clinical management: Berthold Langguth MD, Peter M Kreuzer MD, Tobias Kleinjung MD, Dirk De Ridder MD. The Lancet - Neurology, Volume 12, Issue 9, Pages 920 – 930 (September 2013). Tinnitus: David Baguley PhD, Don McFerran FRCS, Deborah Hall PhD. The Lancet, Volume 382, Issue 9904, Pages 1600 – 1607 (9 November 2013). Prevalence And Characteristics Of Tinnitus Among Adults: Classification and epidemiology of Tinnitus. Heller AJ et al, Otolaryngology Clinics of North America. (2003) 36: 239-248. The Cochrane Reviews: Tinnitus - Anticonvulsants for tinnitus. Antidepressants for patients with tinnitus; Cognitive behavioural therapy for tinnitus; Ginkgo biloba for tinnitus; Hyperbaric oxygen for idiopathic sudden sensorineural hearing loss and tinnitus; Repetitive transcranial magnetic stimulation for tinnitus; Link to Podcast Sound therapy (masking) in the management of tinnitus in adults; Tinnitus Retraining Therapy (TRT) for tinnitus. Wiley and Sons, 2013. Diagnostic Approach to Tinnitus: RW Crummer, M.D., and GA Hassan, M.D. American Family Physician. (2004) 69(1):120-126. Evidence-based Practice Centre - Systematic Review Protocol. Project Title: Evaluation and Treatment of Tinnitus: a comparative effectiveness review: Protocol published online: www.effectivehealthcare.ahrq.gov (February 22, 2012). Similarities between chronic pain and tinnitus. Moller AR. American Journal of Otolaryngology (1997) 18: 577–85 and also on MedlineWeb of Science. A review of evidence in support of a role for 5-HT in the perception of tinnitus. Simpson JJ, Davies WE. Hearing Research (2000) 145: 1–7 and on MedlineWeb of Science Randomized clinical trials for tinnitus: not the last word? Dobie R. In: Patuzzi R. (ed) Proceedings VIIth International Tinnitus Seminar. Perth: University of Western Australia, (2002) 3–6. The neurophysiological model of tinnitus and hyperacusis. Jastreboff PJ. In: Hazell J. (ed) Proceedings of the Sixth International Tinnitus Seminar. London: Tinnitus and Hyperacusis Centre (1999) 32–38. Similarities between severe tinnitus and chronic pain. Moller AR. Journal of the American Academy of Audiology (2000) 11: 115–24, and on Medline. Re-organisation of auditory cortex in tinnitus. Mulnickel W, Elbert T, Taub E, Flor H. Proceedings of the National Academy of Science, USA (1998) 95: 10340–3.

9. Tinnitus Talk March 2014 www.tinnitus.asn.au Page 9RESEARCHA short stay in darkness may heal hearing woes Call it the Ray Charles Effect: A young child who is blind learns to hear things others cannot. Researchers know that young brains are malleable enough to re-wire some circuits that process sensory information. Now researchers at the University of Maryland and Johns Hopkins University have overturned conventional wisdom, showing the brains of adult mice can also be re- wired to compensate for a temporary vision loss by improving their hearing. This may lead to treatments for human hearing loss. Minimising a person’s sight for as little as a week may help improve the brain’s ability to process hearing. When adult mice were kept in the dark for about a week, neural networks in the auditory cortex, where sound is processed, strengthened their connections from the thalamus, the midbrain's switchboard for sensory information. As a result, the mice developed sharper hearing. This enhanced image shows fibres (green) that link the thalamus to neurons (red) in the auditory cortex. The findings, published in the journal Neuron, may lead to treatments for people with hearing loss or tinnitus, said Patrick Kanold, an associate professor of biology at UMD who partnered with Hey-Kyoung Lee, an associate professor of neuroscience at JHU, to lead the study. "There is some level of interconnectedness of the senses in the brain that we are revealing here," Kanold said. "We can perhaps use this to benefit our efforts to recover a lost sense," said Lee. "By temporarily preventing vision, we may be able to engage the adult brain to change the circuit to better process sound." The auditory system in the brain of a very young child quickly learns its way around its sound environment, becoming most sensitive to the sounds it encounters most often. But once that critical period is past, the auditory system doesn't respond to changes in the individual's sound- scape. "This is why we can't hear certain tones in Chinese if we didn't learn Chinese as children," Kanold said. "This is also why children get screened for hearing deficits and visual deficits early. You cannot fix it after the critical period." Kanold, an expert on how the brain processes sound, and Lee, an expert on the same processes in vision, thought the adult brain might be flexible if it were forced to work across the senses rather than within one sense. They used a simple, reversible technique to simulate blindness: they placed adult mice with normal vision and hearing in complete darkness for six to eight days. After the adult mice were returned to a normal light-dark cycle, their vision was unchanged. But they heard much better than before. HAVE YOU REMEMBERED TO RENEW YOUR MEMBERSHIP? Subscriptions were due in January. Subscriptions are the life-blood of the Association and other members donation/s is paying for the expenses we incur on behalf of members who not pay their membership fees in a timely manner. If we did not receive advice of cancellation then your subscription is due and payable now. PLEASE SEND IN YOUR MEMBERSHIP FEES.

10. Page 10 www.tinnitus.asn.au Tinnitus Talk March 2014 RESEARCHA POSSIBLE PLAN TO DISABLE MENIERE'S DISEASE Researchers at University of Colorado School of Medicine may have figured out what causes Meniere's disease and how to attack it. According to Carol Foster, MD, from the department of otolaryngology and Robert Breeze, MD, a neurosurgeon, there is a strong association between Meniere's disease and conditions involving temporary low blood flow in the brain such as migraine headaches. Up until now, the cause of the attacks has been unknown, with no theory fully explaining the many symptoms and signs of the disorder. "If our hypothesis is confirmed, treatment of vascular risk factors may allow control of symptoms and result in a decreased need for surgeries that destroy the balance function in order to control the spell" said Foster. "If attacks are controlled, the previously inevitable progression to severe hearing loss may be preventable in some cases." The researchers propose that a fluid buildup in part of the inner ear, which is strongly associated with Meniere’s attacks, indicates the presence of a pressure-regulation problem that acts to cause mild, intermittent decreases of blood flow within the ear. When this is combined with vascular diseases that also lower blood flow to the brain and ear, sudden loss of blood flow similar to transient ischemic attacks (or mini strokes) in the brain can be generated in the inner ear sensory tissues. In young people who have hydrops without vascular disorders, no attacks occur because blood flow continues in spite of these fluctuations. However, in people with vascular diseases, these fluctuations are sufficient to rob the ear of blood flow and the nutrients the blood provides. When the tissues that sense hearing and motion are starved of blood, they stop sending signals to the brain, which sets off the vertigo, tinnitus and hearing loss in the disorder. Restoration of blood flow does not resolve the problem. Scientists believe it triggers a damaging after-effect called the ischemia-reperfusion pathway in the excitable tissues of the ear that silences the ear for several hours, resulting in the prolonged severe vertigo and hearing loss that is characteristic of the disorder. Although most of the tissues recover, each spell results in small areas of damage that over time results in permanent loss of both hearing and balance function in the ear. Since the first linkage of endolymphatic hydrops and Meniere's disease in 1938, a variety of mechanisms have been proposed to explain the attacks and the progressive deafness, but no answer has explained all aspects of the disorder, and no treatment based on these theories has proven capable of controlling the progression of the disease. This new theory, if proven, would provide many new avenues of treatment for this previously poorly-controlled disorder. Source: Colorado School of Medicine, Dec. 2013 HYDERABAD: MOBILE MENACE Excessive use of mobile phones is driving Hyderabadis literally crazy, as scores of mobile phone users are rushing to experts, saying they are hearing strange sounds. ENT specialists said they are seeing two dozen new patients every month with tinnitus being reported in the city. The mobile phone can be a dangerous device when used excessively not only for phone calls but also for listening to music for long periods," said Dr E C Vinay Kumar, Senior Consultant Surgeon, Department of ENT, Apollo Health City. One salesperson said, "A few months ago, I started feeling pain in my ears and would randomly imagine my phone ringing even when it was on silent mode. It started disturbing my sleep pattern and daily activities," said the 25-year-old, who after being diagnosed with the condition, had to wean herself away from mobile phones in the next two months. A recent International study published worldwide reveals that those who used their phones on both ears, and those who had used a mobile for four years or more were twice as likely to have tinnitus. The study also said that those who used mobile phones for an average of 10 minutes per day were 70% more likely to get the condition. Some experts strongly suggest that the high microwave energy produced by mobile phones during use is most likely to be the causative agent of tinnitus. If mobile phones must be used at all, people should opt to use hands-free sets, instead of placing the handset directly onto the ear. The blue-tooth device being used lately is not advisable either. Ideally, mobile phones should be used only for emergencies and we should all go back to the good old landline to keep our ears safe," he said. The Times of India, Dec. 2013

11. Tinnitus Talk March 2014 www.tinnitus.asn.au Page 11 Editorial by Radha Naidoo H Happy New Year Members! How quickly the months are passing by – we’re almost in the first quarter of the year. The ATA would like to extend our sincere thanks to everyone who kindly made donations. The donations disappointingly were much lower than in 2012 (at close of our financial year at December 2013). You will note from the enclosed financial statement that, had it not been for the bequest from one of our wonderful (now late) members the ATA would have been in dire straits financially last year! This late member had dreadful tinnitus and she rang for help frequently. In her words “the talks I have with you helps me cope with this monster in my head”. What a generous and wonderful legacy she left the ATA! As the first tinnitus Association in Australia, we’ve always helped people from every State in Australia, as well as overseas. As a matter of fact, we have quite a few international members! However, the burden on the ATA has increased tremendously, since the Tinnitus Association of Victoria has been forced to discontinue a range of services. The only service to remain for people with tinnitus is access to their website. Unfortunately, as good as the information on our websites is – people still need to talk to someone. And this is where ATA has always “come into its’ own!” Not everyone’s tinnitus symptoms are the same, and in most cases it’s coupled with anxiety and depression. The myriad of websites, some with good information, is not much use to people who need help urgently. They want to talk to someone - someone who cares about what they’re going through - to help put their fears to rest. The ATA has always prided itself in putting its members first – the people who really need the help – by providing essential services to the tinnitus community. We hope we can continue to be able to help in the years ahead. Speaking of which, you will note from an excerpt from the correspondence from NSW Health. It would appear that NSW Health is taking a little longer inrevising its approach in the implementing the “reforms”. As far as the ATA is concerned they can take all the time they need! With thanks and with hope, I look forward to seeing what the year may bring. GOOD NEWS! GOOD NEWS! Well For the time being ananananyway.yway. An excerpt from the correspondence we received from NSW Health. Partnerships for Health originally proposed the new funding framework would be in place by mid-2014. However in September 2013, NSW Health extended the implementation timeframe to 2015. NCOSS* supports the revised approach to allow more considered implementation of the reforms. NSW Health is undertaking a staged approach to the implementation of the non government organisation. Continuity of Services Almost all NGO funding under the existing NGO Grants Program has been extended until June 2015 to ensure important health services continue to be delivered to the community whilst NSW Health works with the NGO sector on future funding arrangements. *National Councl of Social Services PLEASE SUPPORT OUR RAFFLE We appreciate & acknowledge our members who purchased raffle tickets. However, we still have hundreds of unsold raffle books. These need to be sold URGENTLY. Please complete the order form for raffle books and send in as soon as possible in time for draw at the AGM on 10 May. We know that times are difficult for many of you but we need your help in seeling these tickets! MANY THANKS.

12. Page 12 www.tinnitus.asn.au Tinnitus Talk March 2014 OPERATING HOURS: Monday to Friday from 9:00am to 5:00pm Mobile: 0431 097 080 – Urgent Calls Only Please. AUSTRALIAN TINNITUS ASSOCIATION (NSW) LTD Address: 2 Leichardt Street, Darlinghurst, NSW 2010PO Box 660, Woollahra NSW 1350 Phone: (02) 8382 3331/3338 Fax: (02) 8382 3333 Email info@tinnitus.asn.auWeb: www.tinnitus.asn.auAustralian Tinnitus Association (NSW) Limited “ATA" is a non-profit company established in December 1984. We are a charity. Our major aims, through the Board of Directors, are to: •Assist tinnitus sufferers in coping with tinnitus •Encourage health professionals to provide support and treatment services for tinnitus sufferers. •Promote community awareness of tinnitus and the preventable dangers of excessive noise causing some forms of tinnitus and deafness. •Assist in any research and prevention programs •Promote exchange of information with overseas tinnitus associations. ATA BOARD OF DIRECTORS PRESIDENT Robert van Eerde SECRETARY Robert van Eerde TREASURER Gael Boon DIRECTORS John Bowen Craig Jones CHIEF EXECUTIVE OFFICE Radha Naidoo TINNITUS TALK EDITOR Radha Naidoo MEDICAL ADVISORS Dr Sean Flanagan Susan Driscoll PATRONS Dr Sean Flanagan Dr James Wright DISCLAIMER No person should alter, discontinue or refrain from taking any medication or cause any person to alter, discontinue or refrain from taking any medication as a result of information obtained from this or any ATA newsletter. Any queries an individual may have about medication should be referred to a competent medical practitioner. While every effort has been taken to ensure the accuracy of information contained within this newsletter, the Australian Tinnitus Association (NSW) Limited, the authors and the editor expressly disclaim liability to any person for the consequences of anything done; omitted or to be done by any such person in reliance, whole or partial, upon any part of the contents of this newsletter. The views expressed in the newsletter do not necessarily represent the view of the Australian Tinnitus Association (NSW) Limited. Copyright: Australian Tinnitus Association (NSW) Limited. No part of this publication can be reproduced without written permission from the Australian Tinnitus Association (NSW) Limited. Contributions are welcome. The editor reserves the right to use or edit as necessary. Advertising is accepted on the basis of presenting information to readers and not as an endorsement from the ATA. SELF-HELP GROUPS* PHONE SUPPORT** Please ring for times for meetings Bathurst* Cate Horsburgh (02) 6339 5677 Brisbane (QLD)* Jill Lindley pandj@tadaust.org.au Rod Murphy 0439 712 397 Canberra (ACT)* Barry Telfer (02) 6241 5240 Central Coast (NSW)** Kerry-Anne Tucker (02) 4328 2816 Darwin (NT)** (08) 8945 2016 Dubbo (NSW)* Jennifer Perino (02) 6889 4894 Lismore (NSW)** Eric Spedding (02) 6622 1612 Maryborough (QLD)** (07) 4121 5222 (Better Hearing Australia) Newcastle** Peter Carr (02) 4963 5357 Parramatta (NSW) * Bill Palmer (02) 9863 2038 Tweed Heads (QLD) * T.B.A. St. George/* Sutherland Shire Michael Winkler (02) 9554 5205 Tasmania* Carol McGhee (03) 6244 5570 (Better Hearing Australia) Wimmera (Vic)* Marie Knight (03) 5382 7501