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The Laryngoscope
©2019TheAmericanLaryngological,
Rhinological and Otological Society, Inc.
Eye Movement Desensitization and Reprocessing as a Treatment
for Tinnitus
John S. Phillips, PhD, FRCS(ORL-HNS) ; Sally Erskine, MD, MRCS(ENT); Tal Moore, BA, MSc, ClinPsyD;
Ian Nunney, MSc; Catherine Wright, RGN
Objectives/Hypothesis: To determine the effectiveness of eye movement desensitization and reprocessing (EMDR) as a
treatment for tinnitus.
Study Design: Single-site prospective interventional clinical trial at a university hospital in the United Kingdom.
Methods: Participants were provided with tEMDR. This is a bespoke EMDR protocol that was developed specifically to
treat individuals with tinnitus. Participants received a maximum of 10 sessions of tEMDR. Outcome measures including tinnitus
questionnaires and mood questionnaires were recorded at baseline, discharge, and at 6 months postdischarge.
Results: Tinnitus Handicap Inventory and Beck Depression Inventory scores demonstrated a statistically significant
improvement at discharge after EMDR intervention (P = .0005 and P = .0098, respectively); this improvement was maintained
at 6 months postdischarge. There was also a moderate but not significant (P = .0625) improvement in Beck Anxiety Inventory
scores.
Conclusions: This study has demonstrated that the provision of tEMDR has resulted in a clinically and statistically signifi-
cant improvement in tinnitus symptoms in the majority of those participants who took part. Furthermore, the treatment effect
was maintained at 6 months after treatment ceased. This study is of particular interest, as the study protocol was designed to
be purposefully inclusive of a diverse range of tinnitus patients. However, as a small uncontrolled study, these results do not
consider the significant effects of placebo and therapist interaction. Larger high-quality studies are essential for the verification
of these preliminary results.
KeyWords:Tinnitus, eye movement desensitization and reprocessing, neurotology, quality of life.
Level of Evidence: 4
Laryngoscope, 00:1–7, 2019
INTRODUCTION trauma-related complaints, particularly posttraumatic
Tinnitus is a common, yet poorly understood condi- stress disorder (PTSD).5
1,2 EMDRtherapy is an eight-phase treatment composed
tion, with a prevalence of about 10% in the United King-
3 of standardized protocols and procedures. These phases fol-
dom. Despite the high worldwide prevalence of tinnitus
and the large number of proposed therapies available, there low a process of history taking, preparation of the patient,
is a distinct paucity of well controlled trials in the literature assessment, desensitization, installation, body scanning, clo-
4 sure and reassessment. During a typical EMDR therapy
to support an effective treatment. Eye movement desensiti-
zation and reprocessing (EMDR) is an integrative psycho- session patients divide their attention between recalling
therapy that involves bilateral stimulation, such as rapid traumatic memories and engaging in a bilateral cue. To
movements of the eyes from side to side. EMDR is gaining enable bilateral stimulation, the original EMDR protocol
popularity as an effective treatment for an increasing num- involved the patient sitting across from the therapist and
ber and broad range of conditions. Since its introduction in following the therapist’s hand repeatedly moving from right
1989, numerous controlled studies have been conducted to to left. As EMDR expanded, other forms of bilateral stimu-
evaluate EMDR’s utility as a treatment for various forms of lation evolved. Rather than relying on eyes tracking a
visual stimuli alone, auditory and/or tactile forms of bilat-
eral stimulation were introduced in addition to the eye
From the Norfolk and Norwich University Hospital National movements or on their own. Shapiro states that “Like CBT
Health Service Foundation Trust (J.S.P., S.E., T.M., C.W.), Norwich, United with a trauma focus, EMDR therapy aims to reduce subjec-
Kingdom; and the Norwich Clinical Trials Unit (I.N.), Norwich Medical tive distress and strengthen adaptive cognitions related to
School, University of East Anglia, Norwich, United Kingdom.
Editor’s Note: This Manuscript was accepted for publication on the traumatic event. Unlike CBT with a trauma focus,
January 7, 2019. EMDR does not involve a) detailed descriptions of the
J.S.P. has paid consultancies with Otonomy. event, b) direct challenging of beliefs, c) extended exposure,
This work was funded by a research award from the British 6
Tinnitus Association. or d) homework.”
The authors have no other funding, financial relationships, or There are a number of common features that promote
conflicts of interest to disclose. EMDR as a potentially viable mode of treatment for indi-
Send correspondence to John S. Phillips, Department of Otolaryn-
gology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, viduals with tinnitus. Tinnitus may be considered as a form
Norfolk NR4 7UY, United Kingdom. E-mail: john.phillips@mac.com of phantom auditory perception, parallels have been drawn
DOI: 10.1002/lary.27841 between individuals with chronic tinnitus and individuals
Laryngoscope 00: 2019 Phillips et al.: EMDR for Tinnitus
1
with chronic pain,7,8 and traumatic personal experiences tEMDR protocol, the study participant is then asked to create a
can influence the maintenance of chronic tinnitus.9–12 There description of their tinnitus that included: 1) an image or a felt
has been recent interest in the use of eye movement thera- sense that represents the study participant’s tinnitus experi-
pies to treat patients with phantom sensations such as ences, 2) negative belief(s) in relationship to the tinnitus experi-
phantom limb pain.13,14 EMDR is used as a treatment for ences, 3) a preferred belief in relation to the experiences, 4) the
chronic pain,15 and the utilization of EMDR for trauma- (usually negative/undesirable) emotions associated with the
related conditions is widely reported.16 In view of these experiences, and 5) the physical sensations associated with
encouraging features, together with emerging evidence the experiences. Subjective ratings of disturbance (SUDS) (rang-
17 ing from 0 = neutral/no distress to 10 = bad/most distressing)
from earlier proof of concept work, the authors of this arti- and the study participant’s subjective validity of the positive
cle embarked on a feasibility study to determine whether a beliefs/cognitions (ranging from 0 = perceiving the belief as
bespoke form of EMDR could be considered to be an effec- completely false to 7 = seeing the belief as completely true) were
tive treatment for individuals with tinnitus. recorded to monitor progress during each session.
After this protocol was established, the desensitization
phase began with one of two forms of bilateral stimulation:
MATERIALSANDMETHODS bilateral eye movements or pulsators for bilateral tactile stimu-
The ethical issues regarding this study were presented to the lation; this was subject to the study participant’s preference.
United Kingdom National Health Service (NHS) National Research The pulsators option had two pulsators held in each hand that
Ethics Service for approval before acquiring local approvals from provided alternating bilateral tactile stimulation. The pulsa-
the Research and Development department of the Norfolk and tors were connected to a battery-operated control box held by
Norwich University Hospital NHS Foundation Trust. the therapist. When turned on, the pulsators provided alternat-
ing gentle vibrations, which could be altered in speed and
length.
Participants Each study participant progressed through the process of
bilateral stimulation sets, pausing and reporting on inner obser-
Patients being treated at Norfolk and Norwich University vations and experienced change between each set. Assuming that
Hospital NHS Foundation Trust were offered the opportunity to the study participant’s thoughts, feelings, images, and physical
participate in this study. Inclusion criteria were: 1) adults aged sensations became less distressing, the therapist asked them to
18 years old and above with the capacity to consent; 2) subjective reconsider how true the positive belief seemed now, and this was
idiopathic tinnitus, specifically chronic decompensated tinnitus, strengthened with short sets of bilateral stimulation. Finally,
with a Tinnitus Handicap Inventory (THI) score of 38 to 100; 3) participants were invited to create a positive statement about
tinnitus for greater than 6 months duration; and 4) willing to their changed experience of their tinnitus, and bilateral stimula-
commit to a full course of EMDR therapy. Exclusion criteria tion was employed to help the participant begin to embed this
were: 1) severe mental health problems (current treatment from newwayofthinkingaboutthemselves.
secondary care mental health services) and 2) difficulty commu- Each study participant was provided with a maximum num-
nicating in English. ber of 10 tEMDR sessions, exclusive of the initial history-taking
session. However, 10 sessions were not required for all partici-
pants. Discontinuation of tEMDR sessions took place when a
TreatmentProtocol participant had completed processing all of their negative
Study participants received EMDR therapy according to a tinnitus-related beliefs and either of the following levels had been
bespoke protocol that was developed specifically for patients attained: 1) a SUDS level of less than 3 or 2) a THI score of less
experiencing tinnitus (tEMDR). This protocol drew on the work of than 18.
18
Shapiro’s original adult-based EMDR protocol and Grant’s2009
19
EMDRprotocol for the treatment of chronic pain. Each partici-
pant underwent a maximum number of 10 sessions of tEMDR
therapy lasting 60 minutes each. tEMDR therapy sessions OutcomeMeasurements
occurred regularly with a frequency of once every 1 to 2 weeks. The primary outcome measure was the THI score. Second-
The tEMDR was administered by a single clinical psychologist, ary outcome measures were the Beck Depression Inventory
accredited as an EMDR practitioner, at the Norfolk and Norwich 20 21
University Hospitals NHS Foundation Trust. (BDI), and the Beck Anxiety Inventory (BAI). Each partici-
An EMDRtherapy session is an individual therapy session pant took part in the study for a maximum of 10 weeks. Outcome
with a trained EMDR therapist. Prior to the initial EMDR ses- measures were administered by a research nurse. Measures were
sion, each study participant was provided with a verbal and writ- recorded at the preintervention assessment (T0), and then fur-
ten explanation of the rationale behind the use of EMDR therapy ther assessments were made at discharge (T1) and 6 months
for their tinnitus. EMDR was provided according to the standard postdischarge (T2). The THI questionnaire was completed prior
eight-phase protocol comprising 1) history and treatment plan- to every contact session with the clinician. In total, the THI ques-
ning, 2) client preparation, 3) assessment, 4) desensitization, 5) tionnaire was completed at consent (T0), before the first EMDR
installation, 6) body scan, 7) closure, and 8) reevaluation. Each session (on the day of the EMDR session), and then before every
study participant worked with the therapist to collect a relevant subsequent EDMR session began (on the day of the EMDR ses-
history and current information about the study participant’s sion) for up to a maximum of 10 EMDR sessions, at discharge
experiences of his/her tinnitus, which provided the basis for an (T1), and then at 6 months postdischarge (T2). This provided a
individually tailored formulation. If the participant experienced maximumof13datapoints.
historical trauma that was psychologically linked to the tinnitus,
the traumatic event(s) was initially processed using the standard
EMDRprotocol. Once the past tinnitus-related trauma was pro-
cessed, and for those participants who did not have past trauma Adverse Events
related to their tinnitus, the tEMDR protocol followed. In the Adverse events were reviewed at every study visit.
Laryngoscope 00: 2019 Phillips et al.: EMDR for Tinnitus
2
= Statistical Analysis
ry loss
14 MidHi hearingsevere Descriptive statistics were reported for all variables at
surge ring MidHi baseline. For the primary and secondary outcome variables,
39 F Left 3 Ear UniSevhea9 86 ateral descriptive statistics were reported for the change from baseline
bilUniSev for their respective recorded time points. A Wilcoxon signed rank
profound=
loss test was also performed to test for differences in the changes
HL; from baseline. All analyses were carried out using SAS statistical
13 dB BiSev
; software version 9.4 (SAS Institute, Cary, NC).
hearing frequencies);
67 F Bilateral3 Noise BiModHi 6 39 71-95 all
s: frequency
los h
12 known hig(across RESULTS
2 0
70 M Bilateral1 Not UniModhearingloss154 hearingand Seventeen individuals with tinnitus were recruited to
midmoderate take part in this study. Of those, three participants with-
11 known dHiring severe drew before completion of their tEMDR therapy. One
0 HL; erate withdrawal was due to work commitments interfering with
32 M Left 1 Not BiMilhealoss9 69
B modunilateral session attendance. For another participant it was the
d =
0 increased awareness that the tinnitus was associated with
l MidHiloss
10 known 41-7 bilateral painful childhood experiences but not feeling in a position
t ring s: UniMod
o 0 = ; to explore this. For the third participant that withdrew, no
49 F Centra5 N BiModhea1 67 los Hi
id explanation was provided as contact with them was lost. Of
s the fourteen participants who completed this study, 50%
MidHilos hearing frequency
9 s BiModMh of the participants were male, and the average age
; hig
57 M Left Stres UniSevhearing074 was 57 years (standard deviation = 12.4). The median
moderatemild duration of tinnitus symptoms was 4 years (interquartile
l range [IQR] = 1–9 years). The median number of EMDR
loss HL; frequency
nts. 8 known dHi dB sessions undertaken by the participants was nine sessions
t ring highunilatera
No. 58 F Left 21 No BiMilhea91 60 = (IQR = 7–10 sessions). Table I summarizes key characteris-
20-40rate tics of the study participants. Table II reports the overall
Participa dHi
loss loss:mode trial results. Figure 1 illustrates the improvements in THI
I. 7 UniMil for individual study participants. Figure 2 illustrates the
tudy Participant ring
S known hea ry; overall improvements in THI for all study participants. No
of 73 F Central5 Not BiModHi 8 43 hearingbilateral
TABLE = adverse events were reported.
(mild Invento At discharge (T1), the median improvement in THI
loss score was 20 (IQR = 16–35), which was a statistically signif-
6 BiModHi
racteristics 0 0 Handicap icant improvement (P = .0005). Eight (57.1%) of the 14 sub-
66 M Bilateral StressBiMildHihearing65 jects had an improvement greater than 20 points. The BDI
Cha scores also improved from baseline, with a median improve-
loss Tinnitus
5 media recommendationsfrequencies);=ment of seven points (IQR = 0–11; P = .0098). For both THI
allTHI
64 F Left OtitisUniMildHihearing56
udiology TABLEII.
A (acrossssing;
loss of Overall Trial Results.
4 known
50 M Bilateral512 Not BiSevhearing77184 reproce Decrease Percentage
Societymoderate Outcome Median (IQR) From T0 PValue* > 20-Point Decrease
and
loss British THI
3 the bilateral T0 62.5 (54–72)
known =
5 hearing to T1 37.5 (34–49) 20 (16–35) .0005 8 (57.1%), 17% to 71%
. BiModHi 0
60 F Left 0 Not 1 55 desensitization
BiMod T6 38.5 (32–46) 24 (11–30) .0009 9 (64.3%), 11% to 61%
s ;
l los according BDI
2 known ing . T0 13.5 (7.5–18.5)
frequencymovement
44 M Bilatera1 Not BiModhear7 47 T1 6.5 (1.0–11.0) 7.0 (0–11) .0098
reportedeye
high=frequency T6 6.0 (1.0–13.0) 6.5 (0–10) .0054
loss been
mild high BAI
1 ring EMDR
has and T0 6 (2–12)
hea s);
67 M Bilateral6 Noise BiModHi 3 72 bilateralmid T1 5 (2–8) 3.5 (2–5) .0625
status=
yr * HL). T6 5.5 (3.0–8.0) 1.5 (0–4) .3125
dHifrequenciesevere
status dB *Wilcoxon signed rank test.
Hearing all
tinnitustinnitus,tinnitusEMDR score * BiMil BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory;
yr of >95
of of of sessionsTHI IQR = interquartile range; THI = Tinnitus Handicap Inventory; T0 = preinter-
Age,SexLocationDurationEtiologyHearingNo.Baseline loss:(acrossunilateralvention assessment; T1 = discharge; T2 = 6 months postdischarge.
Laryngoscope 00: 2019 Phillips et al.: EMDR for Tinnitus
3
Fig. 1. Change in Tinnitus Handicap Inventory (THI) score for individual study participants. EMDR = eye movement desensitization and
reprocessing.
and BDI, the improvement was also maintained at the the 14 subjects having an improvement greater than
6-month follow-up (T2). THI scores improved by a median 20 points. The BAI scores had a statistically nonsignificant
of 24 points (IQR = 11–30; P = .0009) with nine (64.3%) of improvement at both discharge and at the 6-month follow-
Fig. 2. Improvements in Tinnitus Handicap Inventory (THI) for study participants. [Color figure can be viewed in the online issue, which is avail-
able at www.laryngoscope.com.]
Laryngoscope 00: 2019 Phillips et al.: EMDR for Tinnitus
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