The authors are to be thanked for their valuable review article (1). We wish to underline the importance of continuous evolution of the therapeutic relationship, and point out the urgent need for qualitative research of complex disorders.

In all experience, the otherwise harmless condition that is tinnitus usually exacerbates when the affected person’s own life is “internally inconsistent.” A developmental step is imminent, and stress is a sign of exhausted coping strategies. Complex mental functions such as self-perception and world view, identity and self-consistency are affected; variables that are complex but can be researched (2).

The cited superior multiprofessional treatment (3) includes, as mentioned by the authors, psychotherapy and counseling, as well as sociotherapy, physical therapy, exercise therapy, and speech therapy, according to the complexity of the disorder and the patient. It is also our experience that in addition to verbal psychotherapy, it is interventions oriented towards the body and the senses that make multimodal therapy effective. The location of the symptom is the auditory system as the “hub,” where the external world is transformed by the sensory stimulus into internal, psychological, experience. And it is there where, in case of increasing tension and discrepancy between the external and internal worlds, the tormenting “warning alarm signal” tinnitus is experienced.

It was surprising to read in the summary that, in addition to behavioral therapy, the main focus in research is on apparatus-based solutions. This gives rise to hopes for simple solutions, but it also implies a reductionist vision of humans and disease. In spite of causing constant impaired hearing, tinnitus fluctuates substantially depending on the subject’s psychological state, something that many studies in (animal) models have not been able to reproduce.

The subject as the actual location of suffering, with dimensions such as development, maturity, self-image, sense, authenticity, and consistency must not be lost. This is only indirectly accessible to drug and apparatus-based treatment, but it plays the crucial part in the sustained recovery from subjective tinnitus.

DOI: 10.3238/arztebl.2013.0600a

Dr. med. Tobias Roeckl

HNO-Klinik Dr. Gaertner, München

t.roeckl@gaertnerklinik.de

Conflict of interest statement

The author declares that no conflict of interest exists.

1.
Kreuzer PM, Vielsmeier V, Langguth B: Chronic tinnitus: an interdisciplinary challenge. Dtsch Arztebl Int 2013; 110(16): 278–84 VOLLTEXT
2.
Fonagy P, Gergely G, Jurist E, Target M: Affektregulierung, Mentalisierung und die Entwicklung des Selbst. Stuttgart: Klett-Cotta 2002.
3.
Cima RF, Maes IH, Joore MA, et al.: Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet 2012; 379: 1951–9 CrossRef MEDLINE
1.Kreuzer PM, Vielsmeier V, Langguth B: Chronic tinnitus: an interdisciplinary challenge. Dtsch Arztebl Int 2013; 110(16): 278–84 VOLLTEXT
2.Fonagy P, Gergely G, Jurist E, Target M: Affektregulierung, Mentalisierung und die Entwicklung des Selbst. Stuttgart: Klett-Cotta 2002.
3.Cima RF, Maes IH, Joore MA, et al.: Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet 2012; 379: 1951–9 CrossRef MEDLINE

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