Treatment of TBI-Related Tinnitus and Comorbid PTSD: Examination of Neurobiological Markers Related to Symptom Improvement

Aim

Conduct a randomized crossover clinical trial with service members and veterans with comorbid mTBI-related tinnitus and PTSD to (1) determine the directionality between the two disorders, (2) clarify the best sequence of therapeutic interventions to alleviate symptoms, and (3) identify neurobiological markers of symptom improvement, potentially to be used as neuromodulatory targets for brain stimulation treatments.

When you think of posttraumatic stress disorder and tinnitus, you might not think they have anything to do with each other. PTSD is a mental health condition that can develop after being part of or witnessing a traumatic event, while tinnitus is a phantom auditory perception—like ringing in the ears—without any objective noise source.

But in fact, they share a strong relationship. They often occur together, particularly after a mild traumatic brain injury (mTBI) or concussion. They cause similar psychological distress with many overlapping symptoms. They also appear to be associated with activity in similar neurobiological networks in the brain.

How do tinnitus and PTSD affect each other?

Like other physical and psychological health conditions, PTSD and tinnitus are often worse when they appear together, but their influence on each other is unclear. Does PTSD make tinnitus worse or more distressing? Does tinnitus exacerbate PTSD symptoms? Or do they have a mutual impact on each other?

There is some evidence that PTSD is the exacerbator, as research shows it impacts tinnitus more than any other potentially co-occurring psychological health condition such as depression. Results of a pilot study led by John Moring, PhD, APBB, at The University of Texas Health Science Center at San Antonio had the same implication. In individuals with PTSD and tinnitus, treatment with a cognitive-behavioral therapy for PTSD called Cognitive Processing Therapy not only led to reductions in PTSD symptoms but also made patients’ tinnitus less distressing.

Research study aims to investigate

Based on these findings, Dr. Moring and his STRONG STAR Consortium colleagues designed a randomized crossover clinical trial with three goals in mind:

  • Shed light on the direction of the relationship between PTSD and tinnitus;
  • Provide guidance for the field on the best sequence of therapeutic interventions (e.g., treat PTSD first or tinnitus first);
  • Identify neurobiological markers in the brain that can be used as neuromodulatory targets for brain stimulation treatments for PTSD and tinnitus.

How the study works

For this study, researchers will recruit 160 military service members and veterans in the San Antonio, Texas, area who have experienced mTBI and who have co-occurring tinnitus and PTSD. Half of study participants will receive Cognitive Processing Therapy (CPT), an evidence-based treatment for PTSD, followed by Progressive Tinnitus Management (PTM), an evidence-based audiology program that includes cognitive-behavioral therapy to help manage tinnitus distress and improve life function. The other half of participants will receive the same treatments but in the opposite order.

Participants in both arms will undergo symptom assessments before treatment begins, between treatment with CPT and PTM, and following completion of both treatments. In addition, 50 study participants will be randomized to receive resting-state functional magnetic resonance imaging (rs-fMRI) before treatment and after all treatment is completed, allowing researchers to identify biomarkers in the brain that correlate with symptom improvement.

Expected outcomes

Findings from this study will shed light on whether (1) it is clinically indicated to treat PTSD prior to TBI-related tinnitus; (2) it is clinically indicated to treat TBI-related tinnitus prior to PTSD; or (3) it is a bidirectional relationship, and either treatment will provide diffuse effects for both PTSD and bothersome tinnitus.

In this way, results are expected to guide clinical practice guidelines regarding the selection and sequence of treatment for those with comorbid TBI-related tinnitus and PTSD, resulting in more immediate relief for the individual. Meanwhile, the neurobiological examination of mechanisms of improvement could lead to the development of neuromodulatory therapies, such as transcranial magnetic stimulation (TMS), to target specific brain regions associated with both conditions.

This could greatly improve care for and the quality of life of the hundreds of thousands of service members and veterans affected by TBI, PTSD and tinnitus. Treatment advances also would extend more broadly to the general population, in which 740 million adults worldwide suffer from tinnitus.

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