A Silver Jubilee Tribute to Pawel J. Jastreboff, Ph.D., Sc.D., MBA
Our specialists Alicja Tobola and Janusz Tobola with good friends and mentors Dr. Pawel J. Jastreboff and Margaret Jastreboff.
An interview with the founder of Tinnitus Retraining Therapy by Michael J. A. Robb, M.D., Oto-Neurologist
This year marks the 25th anniversary of Tinnitus Retraining Therapy (TRT) and the neurophysiological model of tinnitus developed by Pawel J. Jastreboff, Ph.D., Sc.D., MBA. Dr. Jastreboff is a neurophysiologist originally hailing from Poland. He is currently Full Professor at Emory University in Atlanta, Georgia, Visiting Professor at University College London, United Kingdom, and is former faculty of both Yale University and the University of Maryland. He accepted the challenge of studying tinnitus in the early 1980s while at Yale under the encouragement of Clarence T. Sasaki, M.D., an otolaryngologist-head and neck surgeon and U.S. Army veteran who served in Vietnam. Pawel’s grandmother had the symptom of tinnitus, but Pawel did not appreciate it at the time. The first accepted animal model of tinnitus, the neurophysiological model of tinnitus and clinical treatment protocols soon emerged. Now 25 years after his seminal 33-page publication entitled Phantom Auditory Perception (tinnitus): Mechanisms of Generation and Perception was published in the August 1990 issue of Neuroscience Research, it has become the most quoted paper in tinnitus literature and Dr. Jastreboff remains dedicated to teaching clinicians and refining the care of patients worldwide. In 1993, he received the prestigious “Robert W. Hocks” award from ATA for his contribution to the field of tinnitus. In 2014, at the 11th International Tinnitus Seminar, he received the “Award for Clinical Excellence” for his 25 years of work in TRT. He generously surrenders his knowledge in hopes of elevating the level of understanding and treatment for those with tinnitus and decreased sound tolerance. In celebration of this silver jubilee, I invited Pawel to this very special interview in hopes that ATA readers could learn more about the kind man who wears his heart on his sleeve and who feels blessed to have saved, and continues to save, quality of life for thousands of patients.
Michael Robb (MR): Thank you, Pawel, for this unique honor to speak to you in celebration of the silver jubilee of your scientific work and TRT.
Pawel Jastreboff (PJ): Well it is I who should be thanking you for your efforts to share your knowledge of TRT and for all the nice things you have said about me.
MR: What kind of a student were you in school?
PJ: I liked difficult problems and I enjoyed tackling seemingly impossible challenges. I never studied one subject too intensely because I found that boring. I was never a straight A student but in high school, I took part in the country-wide Olympics in Physics, Chemistry and Astronomy; I made it to the final level of all of the Olympics, received Distinction in Chemistry and consequently earned free entrance to the University of Warsaw. There I studied electroacoustics and electronic engineering for my first master’s in science degree and majored in biophysics for my second M.S., degree. My post-graduate work was in neurophysiology and electrophysiology and I earned my Ph.D., from the Polish Academy of Sciences. My post-doctorate work was at the University of Tokyo, Japan and subsequently a habilitation degree (Sc.D.) from the Polish Academy of Sciences. Later on in my career, I obtained a master’s degree in business administration from Emory University.
MR: Are your children following in your footsteps?
PJ: No. My daughter shares an interest in studying brain function using functional magnetic resonance imaging (fMRI), but she focuses on obesity and diabetes. I have one son who works in finance and is an executive at JP Morgan in Hong Kong.
MR: What are the main interests, passions and contributions of your wife, Margaret M. Jastreboff, Ph.D.?
PJ: Margaret was always a very curious person with broad interests, passion, ideas and a lot of energy. Her background is in pharmacology, cellular and molecular biology with a Ph.D., in cell biology and anti-cancer research. She conducted cancer research for 15 years. In 1991, she joined my group, initially in the lab, and later worked with patients. Her main contribution is recognizing the phenomenon of misophonia or those who have adverse reaction to specific everyday sounds. She is passionate about treating children, particularly with autistic spectrum disorders who have decreased sound tolerance. Together, we devised protocols for misophonia treatment. She encourages me to go easy on theory and work on implementation via language that is easy to understand. She argues with me all the time.
MR: When you drafted the neurophysiological model of tinnitus and explained the critical role of the cochlea (generation), the brainstem (detection), the limbic system (fear and emotion), the autonomic system (fight or flight response) and the cerebral cortex (perception and evaluation of tinnitus) in problematic tinnitus vs. the classical auditory system playing a secondary role, were you aware of the ongoing research by Joseph LeDoux, Ph.D., at New York University on the amygdala and the human fear response?
PJ: No. I was not aware of him or his research in 1990 and even for several years later. I ended up using the terms “upper loop and lower loop” to describe important out that he was calling these same neural circuits the “high road and low road.” Through the years, I have gotten to know him and we have discussed our mutual interests at scientific meetings.
MR: What distinct contribution did your British otolaryngology colleague Mr. Jonathan W. R Hazell and audiologist Jacqueline Sheldrake make to TRT?
PJ: The contribution of Mr. Hazell and Ms. Sheldrake has been very important. I had been instructed in the method of tinnitus masking personally by Jack Vernon, Ph.D., which at the time was also in use by Jonathan and Jacqui. On October 12, 1988, as a part of my travel around Europe, I stopped in London and met with Jonathan and Jacqui. Jonathan described their program to me, which was totally based on masking, while Jacqui shared an everyday clinical observation with me. She noticed that tinnitus patients were improving using a lower level of sound therapy that was not completely masking the tinnitus. This was exactly as predicted by my neurophysiological model. Then I described to them my model including the concept of habituation and the clinical method based on my model which later was named Tinnitus Retraining Therapy. They liked it so much that they switched from masking to what is now known as TRT and very quickly saw positive results which were much better than masking. The meeting led to years of friendship with Jonathan complete with long constructive discussions that helped in shaping the TRT protocol. Initially, I did not have clinical experience and Jonathan shared with me his experience as a clinician. While he did not contribute to the neurophysiological model, to the scientific basis of TRT or misophonia, he was very helpful in shaping the clinical implementation of TRT as well as the propagation of TRT in England and Europe in the 1990s. Jonathan helped me translate the model from theory into the clinic so the patient could understand everything. He helped to squeeze the idea out of me and put the rather difficult concepts into words which could be used during counseling. Jonathan’s significant input made the tinnitus clinic in Baltimore, Maryland better.
MR: Who was the linguist who contributed to the generation of the term misophonia?
PJ: Guy Lee, a Latinist at St. John’s College in Cambridge who died in 2005. He was the father-in-law of Jacqueline Sheldrake, collaborator of Mr. Hazell. He was a scholar in Greek to Latin translations. At my request, he sent us a number of pre and post fixes indicating a negative reaction to sound. “Miso” means hate in Greek and “phonia” means sound thus “hatred of sound;” but the term misophonia should not be translated literally. It describes a patient’s negative reactions to specific patterns of sounds. Anecdotally, the additional factor in selecting this word was because I love miso soup.
MR: What would Professor Lee teach us about the proper pronunciation of tinnitus?
PJ: “Tee-nee-toos” is the correction pronunciation, neither “tin-eye-tus” nor “tin-uh-tus” are correct despite their common usage.
MR: What have you found to be helpful for patients with misophonia?
PJ: Since 2000, TRT has enjoyed an 85% success rate for misophonia based on our study of 200 consecutive patients seen at Emory in Atlanta. So far, we have seen about 1,000 misophonic patients. Many tinnitus patients have simultaneous decreased sound tolerance which consists of misophonia and/ or hyperacusis (abnormal loudness tolerance levels). The TRT method has to be properly modified for these patients. Our publications on decreased sound tolerance can help educate those who are interested in the use of TRT in misophonic patients.
MR: What do you think will be the mechanism of the drug that cures non-pulsatile subjective tinnitus for most people with sensorineural hearing loss?
PJ: I believe it will be impossible to find a medication to cure tinnitus (meaning removing the tinnitus perception) because the neurophysiological mechanisms involved in tinnitus perception are too intertwined with the normal function of the auditory system (e.g., it is possible to evoke tinnitus just by spending a few minutes in a very quiet environment). I remain skeptical about medications for the cure of tinnitus. I have an ongoing bet with one prominent tinnitus researcher and clinician about when a cure will emerge, and I keep winning free beer each time we meet and there is still no cure. It is important to realize that TRT offers not only effective treatment for tinnitus but also treats related symptoms like anxiety and depression associated with tinnitus. Post-treatment tinnitus no longer interferes with the patient’s life as it did before.
MR: What are the common misperceptions, misunderstandings and errors in the implementation of TRT?
PJ; Common misconceptions include: focusing on the conscious, cognitive part of the brain and ignoring the crucial role of subconscious centers; ignoring the fundamental role of conditioned reflexes; treating only tinnitus without concurrently treating hyperacusis and misophonia and without alleviating the effects of hearing loss; belief that use of ear-level instruments (i.e., sound generators, combination devices, hearing aids) are sufficient to achieve improvement; and ignoring the importance of specific counseling based on the neurophysiological model. Common errors are: counseling that is too general or too abbreviated and not tailored to the patient’s educational level, specific needs and background; inconsistent counseling from a team treating the patient; false promises about the perception of tinnitus going away forever; use of shortcuts in the treatment without sufficient experience and understanding of TRT; inappropriate diagnosis (categorization) of patients; improper use of sound generators; too much medication that inhibits neural plasticity; running loud audiological tests when patients have decreased sound tolerance; and lack of follow-up visits.
MR: How has TRT changed over the past 25 years?
PJ: The model did not change over that time; however, its clinical implementation changed quite a lot. For example, we introduced the concept and treatment of misophonia, put more stress on retraining the subconscious part of the brain, and substantially changed the sound portion of the therapy. As a result of all of these changes, the time required for seeing improvement shortened substantially. In the early days, it took on average one year of TRT before patients saw some improvement. Nowadays, they may begin to see improvement in one month.
MR: Is it true that some patients can habituate reaction and perception to tinnitus even if they are taking benzodiazepines like Xanax® (alprazolam), Ativan® (lorazepam), Klonopin® (clonazepam), Valium® (diazepam), and others?
PJ: The neural plasticity of the brain is essential in the habituation process. In my experience, doses of Xanax (alprazolam) greater than 1.5 mg per day basically block the habituation process, thus preventing successful outcome of the treatment. Moreover, withdrawal from benzodiazepines may increase or even create the tinnitus perception. Therefore, while it is possible to achieve habituation over a longer period of time when patients are on relatively small doses of benzodiazepines, larger doses of benzodiazepines prevent habituation from occurring. Approximately one third of my patients were on benzodiazepines when I first saw them.
MR: What percentage of patients experience tinnitus relief from the use of hearing aids only?
PJ: In my experience, if hearing aids are used alone, the success rate is about 15%; when hearing aids are used as part of TRT, the effectiveness is over 80%.
MR: Which sound therapy devices do you favor and why?
PJ: Sound is more important than any particular device. Consequently, the optimal device depends on the specific patient. Since the majority of tinnitus patients have hearing loss, the combination devices (hearing aid plus sound generator in one shell) are optimal. For misophonic patients, who typically have normal hearing, sound generators are recommended. The stress should be placed on sound and not on the particular instrument. In my experience, if hearing aids are used alone, the success rate is about 15%; when hearing aids are used as part of TRT, the effectiveness is over 80%. Fixation on a device will cause patients to be constantly reminded of tinnitus. Background sound enrichment is important as well. I am not dogmatic about one particular brand of instrument but reliability is paramount; using two devices, one in each ear, is crucial. The use of sound at night (but not ear-level devices) is recommended given the subconscious role of the brain in habituation of tinnitus reaction. There are several companies making good sound therapy products that can be worn in the ear to facilitate habituation. The most important criteria is that the product should be robust and not breakdown easily. Patients tend to go berserk if their devices are not working properly or fixed promptly. Modern technological features for hearing aids plus sound generators such as remote controls, wireless transmission, and cellphone applications can be very helpful. The Step Method can be used for setting the sound and real ear measurements by the audiologist are ideal. Settings that are too low or too high are bad. This is why patients need to seek care with trained and skilled tinnitus specialists so that counseling is consistent with the neurophysiological model of tinnitus, errors are mmimized and chances for success are maximized.
MR: Is it common or uncommon for patients to report to you that the tinnitus perception seems softer, quieter, more in the distant, lower in pitch, or some other favorable change in perception after TRT?
PJ: On average, patients report that the subjectively perceived tinnitus loudness goes down to about 50% of its initial, pretreatment level. Typically, the pitch is perceived as the same before and after TRT. More importantly, patients achieve a state where tinnitus becomes a neutral signal and they cease experiencing emotional and autonomic reactions. This is called habituation of reaction and it allows patients to eliminate tinnitus as a detractor from their quality of life. Since habituation of tinnitus-evoked reactions can take place during sleep as well, it is important to take advantage of sound therapy all night long.
MR: What techniques did you find work best to help restore sleep? Nighttime use of sound therapy? Sound pillow?
PJ: Since habituation of tinnitusevoked reactions can take place during sleep as well, it is important to take advantage of sound therapy all night long. This strategy can help reduce the relative strength of tinnitus and improve sleep while facilitating the process of habituation. Ear-level devices are not optimal for use during the night. Typically, patients use tabletop sound machines and/or sound pillows. Using sound therapy all night long is an effective method for improving sleep quality which is disrupted in the majority of tinnitus patients.
MR: How many suicide cases due to tinnitus have you experienced in your career and what did you learn from those sad experiences?
PJ: Available data from specific studies conducted to evaluate this issue reveal that there are actually less suicides in the tinnitus population vs. the general population. Throughout 25 years of my practice and over 2,000 patients, I can recall only two cases of suicide. One occurred prior to the patient seeing me in the clinic. The other case involved a patient who, after the initial visit, did not follow TRT, never came back for follow-up visits, and a few years later committed suicide. I do refer to psychiatry and psychology when necessary.
MR: What is the prevalence of patients with psychological/psychiatric problems in your experience?
PJ: Many patients have depression and anxiety that is typically tinnitusevoked. However, less than five percent of my patients need help from psychologists or psychiatrists. This proportion is similar to numbers reported by Jonathan Hazell’s clinic and from observations in Spain. Professionals who work with tinnitus patients should never underestimate pre-existing psychological/psychiatric problems that are distinct from tinnitusevoked depression and anxiety, which, in the majority of cases, disappear with successful treatment of tinnitus. One of my patients once said, “My depression related to tinnitus disappeared and now I just have my good old depression which I’ve had for the last 20 years.”
MR: In my experience,the most challenging group of tinnitus patients are those with very loud, cacophonic, distressing tinnitus and decreased sound tolerance in a single-sided deafness scenario (either moderate, severe or profound hearing loss in one ear). Are you excited about the role that cochlear implants may play in suppressing the tinnitus perception in these patients?
PJ: Actually, I have a number of patients with unilateral deafness who improved very well. I do not use or recommend cochlear implants on these patients but rather suggest CROS or BiCROS hearing aid systems. The method is based on combining information from the visual and auditory systems and is very effective. When using cochlear implants in patients with total deafness and tinnitus, it is necessary to remember that while it is helpful for about 40% of patients, some patients may experience a worsening of tinnitus after cochlear implantation.
MR: What factors disqualify a patient from successfully habituating using TRT?
PJ: In about 90% of cases, it is possible to achieve at least some improvement. However, there are factors which decrease the probability of success or even block it. Specifically:
1) benzodiazepines Xanax® (alprazolam) use greater than 1.5 mg per day;
2) financial interest, e.g., litigants involved in car accidents or dental/ medical procedures with adverse outcomes, disability applicants;
3) using tinnitus/hyperacusis to attract social attention.
MR: How do you determine the end of treatment?
PJ: When tinnitus is no longer a factor in the person’s life. Rating scales are very helpful. A Tinnitus Handicap Inventory (THI) score less than 20 out of 100 is a goal. The average initial THI score of my typical patient is 64/100. A subjective score of 0-2/10 on the impact of tinnitus on life is another good goal. I impose TRT treatment for a minimum of nine months (to prevent relapse) but certain patients need one to two years of treatment. There will be no change in tinnitus pitch match but the subjective loudness of the tinnitus on average decreases by about 50%.
MR: Have you had any success incorporating tinnitus education and TRT in the medical, neurology and otolaryngology residency programs?
PJ: No. Zero success. Our chapters have been written on tinnitus and TRT and included in major Otolaryngology textbooks but no clinical teaching rotation has ever been established. However, the goods news is that the audiology programs have been very receptive to my work. While Adjunct Professor at Salus University, we described the basis of TRT to over 25% of the doctors of audiology (Au.D.) in the USA. Many more audiologists have attended our Tinnitus and Hyperacusis course in Atlanta as part of their training. About 2,000 audiologists are familiar with the basis of TRT now.
MR: What are your plans nowadays since you have obtained your MBA? Do you foresee a master plan where the delivery of tinnitus care can be commercialized efficiently in order to reach more people faster yet safely and ethically?
PJ: Formal certification in TRT is long overdue. The current TRT Association is reasonably good but not good enough. Back in 1990,1 was a naive scientist and academician. I did not patent TRT because I was concerned that this move would erect barriers to clinical care and implementation of TRT. If TRT was patented, maybe I would be rich by now. I do not wish to franchise TRT. The diagram of the neurophysiological model of tinnitus is copyrighted. Audiologists, more than any other specialists, are taking the TRT course and learning how to implement TRT in clinical practice.
MR: What advice do you have for future tinnitus and sound tolerance clinicians?
PJ: Use common sense. Do not reject anything which is not harmful. Do no harm. TRT is a philosophical model and a guide. I did not patent TRT, hence, there are no barriers to its implementation. There are many treatments available now, but no method is as effective as TRT. For example, cognitive behavioral therapy (CBT) does nothing for decreased sound tolerance and hearing loss and published results show that it is not as effective as TRT. TRT can help save the quality of life of patients with tinnitus, decreased sound tolerance and misophonia. I have been working in the field since 1983, and I plan to continue my work with patients. By my work, I do hope I am not just saving a life but I am saving the quality of the life. This makes me happy.
P. J. Jastreboff and M. M. Jastreboff, 2014 Pawel J. Jastreboff, Ph.D., Sc.D., MBA is Professor of Otolaryngology. Head & Neck Surgery at Emory University School of Medicine in Atlanta, GA. He is a co-author of over 130 papers, 170 abstracts, and three books. He founded the first Tinnitus & Hyperacusis clinic in the U.S. at the University of Maryland in 1991. Michael J. A. Robb, M.D., is an Oto-Neurologist in solo private practice at the Robb Oto-Neurology Clinic in Phoenix, Arizona. He was a student of Mr. Jonathan W. P. Hazell in London, 1994-95.
Interview with Dr. P Jastreboff reused with permission from The American Tinnitus Association, http://www.ata.org reprinted from Tinnitus Today Vol.40 Number 3 Winter 2015
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