A Case Report:Traditional Chinese Medicine for Curing Psychosomatic Tinnitus Symptoms

Yu Guo ,Jie Chen2

1Shanghai Municipal Traditional Chinese Medicine Hospital Affiliated to Shanghai University of Traditional Chinese Medicine,Shanghai,China.2Tianshan Traditional Chinese Medicine Hospital,Changning District,Shanghai,China.

#Yu Guo and Jie Chen contributed equally to this work and shared the first authorship.

Abstract Patients with tinnitus are associated with adverse psychological reactions to varying degrees.Psychological interventions are currently the primary treatment to help patients eliminate negative responses to tinnitus.Traditional Chinese medicine uses four diagnostic methods or consultations.Interrogation is one such method.Through consultation,doctors can analyze the causes of tinnitus in patients,collect an accurate description,and assess the severity of the condition.At the same time,when doctors ask about other symptoms in a guided manner,they help patients refocus their attention to the symptoms so that their perception of tinnitus is changed,the vicious circular thinking patterns are broken,and their quality of life improves.When the patient understands why the physician establishes a medical plan,they are willing to cooperate actively and participate in a constructive doctor–patient relationship.This article analyzes the clinical methods and techniques of diagnosing tinnitus patients from the vantage of psychosomatic medicine,which has particular significance for the clinical treatment of tinnitus.

Keywords:Psychosomatic Medicine,Tinnitus,TCM Interrogation,Cognitive behavioral therapy

Introduction

Tinnitus refers to the perception of one or more sounds in the ear or skull in the absence of an external sound source.Two types classify how sound is heard:objective tinnitus and subjective tinnitus.Subjective tinnitus cannot be detected and is caused by abnormal activities in the auditory system.It is a very complex disease with a multifactorial origin[1].There are many etiologies of tinnitus,including damage to the auditory system,changes in hormone levels,and sleep disorders.Some scholars believe that tinnitus is a vital signal,similar to the sounds produced by the body,such as heartbeat and breathing [2,3].Some studies suggest that all tinnitus patients experience varying degrees of anxiety and depression [4].Various non-pharmacological interventions for adverse psychological reactions have become one of the important mainstays of tinnitus treatment.It is the primary recommended method to help patients with specific psychological indications to eliminate negative responses while receiving necessary information and support.Traditional Chinese medicine (TCM) has included emotional care since ancient times.InMedical Law– Inquiry on Diseases,a passage reads:“Medicine is benevolent.A benevolent gentleman must be devoted to emotion.”Eastern Medicine Treasuresays:“To eliminate one’s disease,you need to correct your heart first;one’s heart must be rectified and be good in truth.”The Three Causesalso points out:“Seven emotions are common human nature,and when enamored,they will be first developed from the viscera,and then shaped in the body.”

Tinnitus patients hear sounds that others cannot hear,sounds coming from their skulls or inside their heads.These auditory and physical sensations induce negative reactions in the patients,gradually forming a vicious circle of compulsive thoughts,aggravating the patients’symptoms.From the analysis of patients’ cognitive models of tinnitus,some misunderstandings are revealed:1) overestimated compulsive thinking:“If there is tinnitus,I am a sick person”;2) overestimated severity of an event’s consequences:“If my tinnitus is not treated well,something bad will happen”;3)pursuit of perfection:“If I have tinnitus,I have a defect”;and 4) underestimated consequences of anxiety:“The purpose of treatment is to make the tinnitus disappear completely,otherwise I will not be able to return to normalcy.” The obsessive state refers to a separate or combination of obsessive thoughts,compulsive emotions,and compulsive actions.Emotions are self-imposed,and an individual’s own feelings are not imposed by others.The obsessive–compulsive mood is common,and everyone has experienced such swings.

Tinnitus is a subjective symptom.Even with a professional hearing examination and a specific clinical diagnosis for tinnitus,symptoms are based on the patients’ subjective judgments.Common clinical symptoms are unilateral or bilateral tinnitus,or persistent or intermittent sounds,such as wind,cicadas,running water,and bells,which are aggravated at night or rest,and may be accompanied by dizziness,a heavy head,chest tightness,fatigue,upset,irritability,dreaminess,insomnia,etc.[5].TCM has had a detailed understanding of tinnitus for a long time.There are many records of it in ancient literature.Ming Yi Za Zhu · Vol 3recorded “Tinnitus syndrome may sound like a cicada ring,from the left or right ear,or sometimes occluded;people mostly treat it as kidney deficiency.”Surgery Syndrome · Vol 2recorded “those with tinnitus,has a sound in whose ear,either if the cicadas ring,or if the bell ringing,or if the fire stubborn,or if the sound of running water,or if the sound of rice shaking,or sleep like fighting drum,such as knocking in the ear.”

Etiology and pathogenesis of tinnitus according to TCM

Although the tinnitus performance is limited to the ear,TCM emphasizes the need for a holistic medical view,meaning each of the five internal organs performs its duties and mutually supports and restricts the other.Therefore,tinnitus is only a symptom.Clinically,the etiology and pathogenesis of tinnitus originate from a regulatory and mental imbalance between the five organs.

Among the five internal organs,most are closely related to the spleen,kidney,and liver.The ear is the tip of the kidney and is perfused by the 12 meridians,which are internalized to the brain.If the kidney essence loses and the marrow is empty in the pulp,the ear will not be able to clear the orifice and tinnitus results.Yi Lin Sheng Mo–Earmentioned:“The ear belongs to the Foot Shaoyin Kidney Channel…Deficiency of Kidney Qi leads to deafness,and insufficient kidney Qi leads to tinnitus.” The liver is the son of the kidneys.Insufficient kidney water or internal depression of the liver,which affect each other,causes chronic illness and deficiency,and inadequate viscera,leading to aggravated tinnitus symptoms.The spleen is the source of Qi and blood biochemistry.Deficiency of spleen Qi means the meridians are empty and cannot be served in the ear.At the same time,if the spleen is deficient and unhealthy,and the damp turbidity accumulates,the upper congestions will not clear,and the ears are covered by the muddy Qi,which causes tinnitus.

Lingshu–Benshensays:“Thoughtfulness in the heart will hurt the spirit,and when the spirit is hurt,you will be afraid to lose your mind.”“Incomprehensible spleen will hurt the mind,and the mental hurt will bring chaos.” “Sorrow liver hurts the soul,and the soul hurt is arrogant.” “Endless blissful lung will hurt the soul and becomes mad.” “Unstoppable angered kidney hurts the mind and is easy to forget one’s preface.”These passages embody the spirit of Chinese medicine.Lingshu–Tian Niansays:“Become a person,you need have blood Qi reconciled and connected,the five zombies well-formed,as well as all the spirit,the mind,and the soul completed.” Consciousness,thinking,emotions,and other spiritual activities are the highest level of human activities.The mind is the master of spiritual activity,which governs spirit,soul,mind,and will.

The heart governs the mind.Suwen–Linglan Secret Code Theoryrecorded “Heart is the official of the monarch,and where the minds come out.” The physiological functions of the human body’s organs require division of labor and cooperation under the control and regulation of the mind.A clear mind can help the liver control venting and regulate emotions.Thinking comes from the heart,and the spleen responds to it.The patient’s perception of tinnitus forces them to enter a mode or cycle of repetitive negative thinking.

Too much sadness hurts the spleen.A mother’s disease affects her children.Obsessive–compulsive patients are often accompanied by anxiety,tension,and depression.Anxiety and tension belong to“worry,”and depression belongs to “sorrow.” Worry and sorrow are formed by the transformation of lung Qi.TheSuwen·Yin-Yang Yingxiang Dalunsays:“Grief hurts the lungs,joy overcomes sorrow.” Excessive anxiety damages the lung Qi,and the lack of lung Qi decreases the body’s ability to tolerate external stimuli.Therefore,it is more prone to emotional changes of grief.If the lung Qi is weak for a long time,the kidneys will be involved,and the brain will be as dissatisfied as a lack of breath,and then tinnitus happens.

TCM treatment for tinnitus

TCM treatment is based on the specific tinnitus sound described by the patient,combined with the symptoms of various viscera systems,including tongue coating and pulse status.The treatment is based on syndrome differentiation.Jingyue Quanshu· Ear Syndromesaid:“Those who scream are mostly solid;those who yell gradually,softer,are likely deficient;those who are young and strong are more solid,and those who are weak and less fiery are likely deficient;Drinking wine has a strong taste and those who have a lot of phlegm and fire are more substantial;those with clearer quality and thinner pulse who are tired are more deficient.”

According to the new onset of chronic disease deficiency,TCM is taken orally to sparse wind,dissipate heat,relieve depression,propagate the orifice,resolve phlegm,pass ear,regulate diarrhea,and invigorate the kidney.Remedies include 1) “Yinqiao San”for treating wind-heat disturbance,2)“Longdan Xiegan soup” for treating liver dampness syndrome,3)“Wendan soup” for treating stagnation of phlegm,4)“Erlong Zuoci pills”for treating kidney deficiency,and 5)“Yiqi Smart soup” for treating spleen deficiency and weak Qi.TCM treatments for tinnitus include acupoint injection,acupuncture treatment,ear acupuncture,and other methods that can effectively strengthen local stimulation and improve clinical efficacy.

Western medicine treatment for tinnitus

Western medicine treatments of tinnitus primarily focus on strengthening the diagnosis and analysis of the etiology of tinnitus and the pathophysiological mechanisms of various types of tinnitus.In the 1990s,Jastreboff [6] proposed a neurophysiological model of tinnitus,which systematically linked tinnitus with cognition,emotion,and behavior,providing new treatment pathways for tinnitus patients.The purpose of cognitive–behavioral therapy (CBT) is to change dysfunctional behaviors and beliefs to reduce symptoms,improve daily life functions,and ultimately promote recovery from illness.CBT therapy has treated tinnitus for decades and is proven to be effective in reducing its severity or pain and improving tinnitus-related fears,cognitive problems,and daily life functions.In recent years,cognitive–behavioral therapy—biofeedback therapy has had a beneficial effect on many physical and mental diseases related to psychosocial stress,providing non-drug intervention assistance for tinnitus patients with adverse psychological reactions[7].

The above-mentioned methods primarily include psychological counseling,relaxation training,and attention-shifting.When used in tinnitus treatment,medical staff implement psychological guidance to counter the patient’s negative psychological reaction.During treatment,after communicating the basic facts about tinnitus to the patient so that the patient can understand the affliction and eliminate fear or stress,the patient is then instructed to close their eyes to rest,meditate,and relax.The patient can use music,television,and natural sounds during the treatment to divert their attention from tinnitus.The sounds can be adjusted to an appropriate range so that the patient can coexist with the tinnitus.

Psychotherapy is the process of using clinical psychology techniques and theories to treat patients with mental illnesses based on a good doctor–patient relationship and guided by the theoretical system of clinical psychology.It is restricted by a series of conditional factors.The doctor must be a psychiatric practitioner,the treatment mode is single,the treatment requires space and time,and the patients must have a high education level and a good expression of psychological adverse reactions.Also,patients have low acceptance of “tinnitus” as the primary complaint and visits to a psychiatric department.They do not think that tinnitus is a psychological disorder of cognitive deficiency but only a somatic disease.

Content of TCM consultation

Inquiry in Chinese medicine is the basic method for clinical diagnosis of diseases and collecting disease information.It is how doctors communicate with patients.Doctors grasp clues about patient diseases and conduct purposeful conversations with them based on their own clinical experience.Da Yi Jing Cheng–A Brief Case of Treating Diseasessays:“To know before you ask.Smart doctors are those who can distinguish the depth of the disease.” The content of the diagnosing questions includes the condition of the disease,the patient’s conscious symptoms,past medical history,and living habits.Song of Ten Questionswas written by Zhang Jingyue,a medical scientist in the Ming Dynasty of China.He summarized the main points from his predecessors’consultations.In the Book ofJingyue Quanshu· chuanzhonglu · Ten Questions:“Q1.about cold and heat,Q2.sweat,Q3.head and body,Q4.stool,Q5.diet,Q6.chest and abdomen,Q7.deafness,Q8.thirst,Q9.Yin and Yang observed through the pulse and color,Q10.spirit from the smell.Although it is not difficult,it must be clear that there is no complaint.” It covers a wide range of ailments and is highly concentrated and refined for clinical diagnosis and treatment.

Advantages of TCM clinical consultation

Break through the barriers to communication

During the consultation process,the doctor’s intense inquiry can make the patient feel thoroughly examined.By interacting with the patient,based on a common pattern between doctors and patients,the patient feels the doctor’s serious concern about their tinnitus problem.The patient is in a low-impedance state,which builds a foundation for a constructive doctor–patient relationship.Medical Law·Questioning the Disease Theorysaid:“If you are sincere,you will not feel annoyed by the questioner,and the patient will not be bored.You can ask the truth in detail,and then the ailment can be corrected.”

Take people as the foremost

The doctor asks appropriate questions according to the patient’s needs.The questions are posed in a peaceful,neutral manner in easy-to-understand language so that the patient can “inspect” his own body changes.This technique activates the patient’s cognition and allows them to guide the doctor to what needs to be treated.The “patient-oriented” consultation process is where targeted inquiries are made as to age,diet,emotional life,geographic factors,disease treatment history,phobias (such as fear of cold or heat),excessive food,ease of hunger,loss of appetite,sleep quality,bedtime,bowel frequency,bowel nature,and much more.Suwen·Zheng Four Loss Theoryexplains:“Without asking about the beginning of the disease,without caring about the eating disorder,living excessively,or poisonous habits,without first knowing this,how can the disease be diagnosed?”

Take advantage of language skills

Chinese medicine questions and diagnoses are based on theTen Question Songs,but differ from the single fixed procedure in the psychotherapy process.It combines other diagnostic and treatment techniques,such as “looking,smelling,and cutting.” It is demonstrated to the patient in a threedimensional mode so that the patient feels the depth of service,diagnosis,and treatment process.There is a saying in theHuangdi Neijing:“Ask the feelings to understand the meaning.”At the same time,the frequency,speed,and moderation of the doctor’s speech also affect the patient’s feelings.During the consultation process,science and health knowledge are appropriately integrated to deepen the patient’s participation in the treatment and reach a mutual consensus on the tinnitus treatment solutions.

TCM methods combined with Western medicine psychotherapy

Unlike Low Resistance State Thought Induction Psychotherapy [8] (Low Resistance State Thought Induction Psychotherapy,or TIP therapy for short),Chinese medicine consultation is not primarily therapeutic but rather a method for doctors to collect information and opinions in clinical practice.It combines medicine and psychology and is an interdisciplinary practice,which helps doctors and patients understand the occurrence,symptoms,development,diagnosis,and treatment of the condition and related diseases.

TCM consultation methods for tinnitus

Through the Chinese medicine consultation,the doctor changes the patient’s cognition and plays a psychological support role with other subjective feelings.When the patient discovers their own emotional disorder,they will not blame themselves and will then accept the tinnitus symptoms and follow the doctor’s plan to learn how to deal with them.The goals are to reduce 100% of the patient’s requirements that tinnitus is cured completely,pay attention to other symptoms that cause tinnitus,understand that tinnitus may be a sign of imbalance from the patient’s own body,and evaluate the tinnitus effect according to the actual situation in the patient’s treatment process.

Consultation content

For first-time tinnitus patients,we use the purposeful interrogation technique for general information,including the patient’s name,gender,age,and occupation.We pay close attention to understanding the origins of tinnitus (such as a history of noise exposure or history of drug poisoning);its development,change,and treatment;the patient’s conscious symptoms of tinnitus (e.g.,the duration of tinnitus,the tone of tinnitus,the loudness of tinnitus,and whether it affects hearing);and other disease-related conditions (including dizziness,poor sleep status,stool condition,and degree of upset).For returning patients,we break the conventional consultation process and avoid questions on tinnitus.Instead,we ask the patient about other discomforts or general conditions related to tinnitus during treatment(dizziness,mood,appetite,sleep quality,smoothness of the second bowel movement,etc.).For feedback on the improvement of systemic symptoms,we initially assess the patient’s treatment satisfaction and tinnitus tolerance,and then we ask the patient’s conscious symptoms of tinnitus (such as its duration,tone,and loudness)and whether it has changed.

Consultation skills

Considering that tinnitus is a subjective patient symptom,from a professional perspective,collecting comprehensive and detailed disease data is imperative for doctors to correctly analyze the condition,determine its location,grasp the disease,and treat the symptoms in the initial consultation.Suwen· Zheng Four Failure Theoryrecorded “without asking about the origins of the disease,without caring about the eating disorder,living excessively,or hurting poison.Without first knowing this,how can the disease be diagnosed?” At the same time,it is also possible for patients to evaluate doctors to fully affirm their professional worthiness and lay the foundation for the establishment of a good doctor–patient consultation model.

In the follow-up consultation,the goal should be to obtain positive and good information from the patient and let the patient feel the effectiveness of the treatment method,focusing on the changes in his body and weakening the adverse impact of tinnitus.Patients are encouraged and supported to provide“unimportant”information when they initially describe their symptoms.This reinforces the benign nature of the relationship between doctors and patients.It can also help doctors better understand the patient’s condition and establish more effective,customized treatment plans.

During the consultation process,doctors use plain and easy-to-understand language as much as possible,avoiding professional jargon and medical terms that are unacceptable or unintelligible to patients.They do not question patients based on personal subjective wishes.At the same time,doctors break through communication barriers with tinnitus patients by practicing the models of “smiling,” “labeling,” and being“patient-oriented”in the consultation process.

Case report

The attached medical records describe the tinnitus treatment from the perspective of psychosomatic medicine combined with TCM clinical examination skills.Ms.Zhu,a 63-year-old patient,complained of repeated right ear tinnitus.Her tinnitus resembled a“cicada” sound with hearing loss.After checking the results of her previous auxiliary examinations,it was determined that her pure-tone hearing threshold presented a high-frequency hearing threshold drop.The tinnitus matching practice indicated that the tinnitus frequency was 8 kHz,and the tinnitus loudness was 8 dB HL（decibel hearing level)above the hearing threshold.The Distortion Product Otoacoustic Emission showed that the high frequencies（3–8 kHz）were all elicited,the stapedius reflex was prolonged,and the binaural acoustic impedance was A-type.According to Ms.Zhou’s self-analysis,the tinnitus symptoms interfered with her social activities(badminton and square dancing) and daily activities(sleep).Ms.Zhu denied any history of psychiatric diagnosis or treatment,taking psychotropic drugs,or attempted suicide.After a series of failed conventional Western medicine diagnoses and treatments,she felt her symptoms did not improve significantly and eagerly sought new treatments in hope of improvement.

Case treatment process

First visit on April 30,2020,through CBT,Ms.Zhu was informed that her previous examination results and treatment plan indicated no organic malignant disease.Therefore,it was possible to relieve her of the burden of fear of disease and its corresponding psychological impact.It was possible to reduce the severity of her screaming and pain and dispel her fears related to wheezing.The treatment involved communicating with Ms.Zhu and explaining that the tinnitus occurrence was related to sleep loss and emotions,which caused a vicious cycle.We found an entry point for treatment to break the vicious circle and recommended treatments for sleep and stress management therapy to first cope with the tinnitus symptoms.Addressing the problem of tinnitus itself would be the focus of the next stage.Ms.Zhu was constantly evaluated,monitored,and treated by a TCM physician with psychological counseling qualifications throughout her treatment process.She was administered the tinnitus questionnaire,visual analogue scale (VAS),Generalized Anxiety Disorder 7 Questionnaires (GAD-7;Spitzer,Kroenke,Williams,&Löwe,2006).

Meanwhile,we provided her with oral Chinese medicine to regulate the heart and kidneys,relieve depression,and help her sleep well,mainly to improve her mood.In addition,we prescribed special Chinese medicine external treatments of otolaryngology(including a Yifeng acupuncture at the three acupoints in front of the ear),music therapy,and other techniques.So-called “Five Tone Music Therapy” was co-developed by Professor Guo Yu,director of the Department of Otolaryngology,Shanghai University,TCM Affiliated City Hospital of TCM,and the Conservatory of Music.We combined local and general treatment of tinnitus and provided regular care.During the initial consultation,the doctor spent time inquiring about Ms.Zhu’s medical history and listening to her health statements,which helped analyze the condition,determine the location,grasp the disease,and provide reliable evidence for the diagnosis and treatment.At the same time,Ms.Zhu was able to evaluate the doctor,affirm the level of professional care,and establish the basis for a good doctor– patient relationship and medical treatment.

May 14,2020,follow-up in 2 weeks,the patient’s sleep actively improved by the time of her second follow-up visit.She informed the doctor about the significant change in the time it took her to fall asleep at the same time he asked about her sleep status.Her family members had previously prevented her from playing badminton and dancing square dance because of her tinnitus,which isolated her and hurt the quality of her life.This important information helped the doctors adjust their treatment methods,thereby improving Ms.Zhu’s sleep cycle rhythms.The feedback was almost completely positive.The treatment method was effective,the state of her body was improved,the adverse effects of tinnitus were alleviated,and her medical compliance on treatment was strengthened.

May 28,2020,follow-up in 4 weeks,at this follow-up visit,the patient actively informed the doctor that her sleep and mood had greatly improved.Her tinnitus complaints were reduced compared with the previous visit.She fully agreed with the doctor’s treatment plan and was willing to actively cooperate,including regular medication and treatment.She practiced the Five Tone Music Therapy regularly at home and followed the other health instructions,actively restoring daily social life and living conditions.

Evaluation method of case outcome

The final evaluation of Ms.Zhu’s case was the tinnitus score scale and the VAS score.The GAD-7 questionnaire was only used as a benchmark measure.Ms.Zhu’s tinnitus scoring scale evaluation at the first visit showed that she was at level 5.For all the scoring subsets,she was at the highest values.At the second follow-up visit,her tinnitus severity score dropped to level 3 (11 points),among which the scores of the subsets “tinnitus affects sleep,” “tinnitus hinders work and study,” and “tinnitus upset” had a significant reduction.In the follow-up visit 4 weeks later,all the sub-item scores showed lower values,and the total score was at level 1.The VAS score item showed that the comprehensive scores of patients,such as the severity of tinnitus and treatment satisfaction,were reduced to varying degrees(Table 1).The reduction on the above two score categories is considered to be a clinically meaningful change.

Table 1 The whole process of tinnitus score scale and VAS scale

Summary and Conclusions

The tinnitus treatment requires patients to carry out cognitive and comprehensive activities in psychological,physical,and social aspects.It requires the doctor to think and communicate with the patients by integrating ideas and life practices during the process of consultation and communication.Through consultation,the doctor can understand the underlying cause of the patient’s tinnitus,capture the patient’s description of the nature of their tinnitus,and assess the severity of the condition.At the same time,when the patient is asked about other symptoms,it helps the patient to refocus on their own symptoms and have a“sudden realization” regarding cognitive changes.Breaking the vicious circle of tinnitus requires an effective treatment plan and partnership with a doctor,understanding why doctors establish medical plans,and a willingness on the patient’s part to actively cooperate.At the same time,the process of TCM consultation establishes a constructive doctor–patient relationship.