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bill clark

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 #1 
Dear Dr. Nagler,

First off, thank you for taking my question.
How do I treat my reactive tinnitus?
I don't mean a reaction to coffee, alcohol, foods, etc.  I'm talking about immediate increase in volume and intensity of my T with the sounds of life...fans, running water from a faucet, microwave, refrigerator, furnace and a/c fans, TV, road noise in the car, etc.  If the exposure to any of these is brief, my T goes back down within a few minutes, but if the exposure is longer, it could last for hours or even an entire day.
My T is very high pitched.  It cannot be masked because of the reaction.  I've tried TRT with hearing aid sound generators and after an hour my T is spiked to unbearable levels and lasts a couple days.
I've had T for 18 years but 4 months ago it became a tortuous condition with pulsing and a number of other sounds that constantly change in tone and intensity.  Prior to this my T was maskable and I had completely habituated to it.  I'm struggling.

Thank you Sir,

Bill
Dr. Nagler

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 #2 
Hello Bill. Welcome to this site. And thank you for your very good question.

Just for clarification, what did your TRT clinician instruct you to do when you told him (or her) what happened when you used your devices as instructed?

Stephen M. Nagler, M.D.

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The best way to find yourself is to lose yourself in the service of others.
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No bird ever soared in a calm. Adversity is what lifts us.
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David McCullough quoting Wilbur Wright
bill clark

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 #3 
She told me to set the volume as low as possible on the sound generator but still be able to hear it.
Dr. Nagler

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 #4 
OK. I need to think a bit about how to answer your question in view of the fact that I do not know the specifics of your situation and can only respond in general, which is to say that if I knew more about the details of your history and evaluation, I might have recommended exactly what your TRT clinician recommended. Please check back tomorrow.

Stephen M. Nagler, M.D.

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The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
bill clark

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 #5 
Ok....thank you.  And if you have specific questions for me that might help, please ask away.
Dr. Nagler

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 #6 
Without getting into matters too deeply, what you describe sounds to me like a Category 1 TRT patient with tinnitus that is aggravated by sound. You might also have an element of misophonia. Hard to say without evaluating you. Anyway, TRT clinicians handle this situation a bit differently depending on a number of factors, but a typical instruction might be to set the devices at a low volume initially but readily audible (as opposed to just barely audible) for ten minutes or so daily the first week and the gradually increase the time wearing them each week until you are wearing them at least eight hours a day. At that point you would start increasing the volume towards the mixing point, but never so loud that they are uncomfortable or distracting. Back when I was in practice, I found it very helpful to do a tinnitus pitch and loudness match at baseline, and then repeat the study when the patient's tinnitus had reacted to sound. Almost invariably the loudness match would be identical. Hard to believe, but true.

Anyway, I'd certainly defer to your own TRT clinician in the above regard since she knows you far better than I.

Hope this helps.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
bill clark

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 #7 
Thank you for that explanation.  She has not mentioned doing that at all.  I really need a different clinic.  This one offers TRT but no therapy with it. 
Also, there really isn't a baseline to my tinnitus.  The pitch consists of 3-5 different sounds that fluctuate almost constantly, and the volume moves up and down many times throughout the day and night.  I describe the pitch as making a fist and alternately moving your knuckles up and down.  What a challenge this has become.
Thank you so very much for your help Dr Nagler.
Dr. Nagler

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 #8 
When you say that your clinic "offers TRT but no therapy with it," do you mean that they offer devices but no TRT counseling? Didn't your TRT clinician discuss the Neurophysiological Model of Tinnitus and explain how your particular case fit into it? Did she discuss the significance of the Heller & Bergman experiment, the role of reaction in severity, etc? I ask because TRT has two components - sound therapy consistent with your TRT category and TRT counseling. Without the counseling, it isn't TRT at all!

There are many effective roads to habituation, TRT being but one. But if it's going to be called TRT, then in my opinion it oughta be TRT.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
bill clark

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 #9 
The initial consultation did include discussion of those items but was very brief.  She said she trained with Jastreboff.  She did not evaluate or classify my case.  I had a current hearing test report I gave to her but she did not check my Tinnitus loudness or pitch.  She sent me home with devices to try before purchasing and referred me to a therapist....who it turns out was not experienced in working with Tinnitus patients.
She called the program she offered TRT, but there were no counseling sessions included other than the initial meeting.  There was an additional charge over and above the cost of the devices which included any adjustments needed for the sound therapy.  The additional charge on the invoice was labeled TRT.

Thank you Dr Nagler.

Bill
Dr. Nagler

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 #10 
Bill, as you may know, I am a "fan" of TRT. That is not to say TRT is the only pathway to habituation - far from it - but TRT is one that has withstood the test of time, the model upon which it is based makes sense, and the science behind it is solid. That said, there are a few problems. Cost is one (although the cost of "not TRT" can be considerable). Accessibility can be another. But the biggest problem in my opinion can be summed up in the following paragraph from my article Tinnitus Retraining Therapy:

"One of the problems with TRT is that the name is not trademarked – so with many clinicians claiming to offer TRT, what you see is not necessarily what you get. And to my way of thinking, that represents an enormous challenge for the tinnitus community. Anybody can call himself or herself a 'TRT clinician.' Moreover, since there is no credentialing or standardization in TRT, even if a clinician has read Dr. Jastreboff's book and taken his course, there is no assurance that he or she has retained the material or even understood it in the first place. It should be noted that there is a 'TRT Association' with members listed on Dr. Jastreboff's website, but Dr. Jastreboff makes a point of stating that it should not be treated as a referral list and that being a member of the TRT Association is not equivalent to certification. As I see it, at best the list should be viewed as a starting point. Moreover, I would be concerned about going to any clinician actually claiming to be 'certified' in TRT. Such certification simply does not exist."

I sincerely wish you well in your search for relief.

Stephen M. Nagler, M.D.



__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
bill clark

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Posts: 17
 #11 
Thank you for that.  I just have to keep faith that however loud or high or low pitched, it can be habituated.  My pitch is extremely high and can't be masked so I just need to grit my teeth and hang on I guess.  Thanks for your help Dr Nagler.
Dr. Nagler

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 #12 
You do not have to "grit [your] teeth and hang on." There are a number of effective approaches towards facilitating habituation of tinnitus. Perhaps start HERE

All the best with it.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
bill clark

Member
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Posts: 17
 #13 
Thank you again for your encouragement Dr Nagler.  That is what I need more than anything.
I am working with a therapist for CBT but it's a long and slow process.
And the external barrier of too much time attending to it is tough when it changes all the time.  It alerts you with every change.
I think if I could partially mask it, that would help.  But when I try, the volume increases.
I've refrained from taking meds but that may be necessary to get through this.  My brain needs help.
Dr. Nagler

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 #14 
Bill, your brain doesn't need help. Your brain is doing exactly what it is supposed to do; it's just doing it too well!

Your brain could probably do with an infusion of good information - but as far as needing help goes, your brain is functioning just fine. As I see it anyway.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
bill clark

Member
Registered:
Posts: 17
 #15 
I did try Clonazepam 2 times at a low dose of .25mg every 12 hours.  The first time I tried it, I quit after 2 doses and the 2nd time I went 4 doses before quitting.  Both times I had adverse reactions about 12 hours after my last dose.  My 4 sounds of tinnitus increased in loudness and intensity for many hours the first time and the 2nd time I experienced louder high pitched squealing than I had ever heard before.  Thank God it went away within a few minutes but intensity and loudness continued for hours again this time.
When you withdrew from Benzos did you experience anything like that?
My quality of life improved considerably while on the meds but I'm afraid to go back for fear of a permanent unbearable change.

Thank you Dr Nagler.

Bill
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Dr. Nagler's Tinnitus Corner is provided for education and information only. It is not intended for the purpose of providing medical care and should in no way substitute for appropriate in-person consultations with qualified healthcare professionals. By using this site, participants agree to hold Dr. Nagler and Atlanta Tinnitus Consultants, LLC harmless with respect to any loss, injury, claim, liability, or damage arising from following the postings herein.