Stress-Related Tinnitus Treatment Protocols

Fig. 8.1
The neurophysiological model

The neurophysiological model is based on the idea that conditioned fear responses elicited by the tinnitus precept are the cause for tinnitus becoming bothersome.

8.3.3 The Cognitive Model

A conceptual cognitive model proposed by McKenna et al. (2014), incorporates a cognitive model of distress to explain tinnitus-associated insomnia (Harvey 2002). McKenna et al. argue that the tinnitus-signal distress and bodily arousal are provoked mainly through negative cognitive misinterpretations, leading to inaccurate evaluations of sensory activity and distorted perceptions (see Fig. 8.2). It is proposed that the resulting stress and hypervigilance contribute to a feedback cycle that exacerbates the distress associated with flawed sensory processing, of which tinnitus may be a major component. The model attributes a fundamental role to the negative evaluation of tinnitus. The negative evaluation of the tinnitus percept can be viewed as comprised of primary and secondary appraisals. For example, a person might initially appraise the tinnitus as being threatening to their health and then make a secondary appraisal of their (in)ability to cope with it.

Fig. 8.2
Cognitive model—reproduced from (McKenna et al. 2014)

The cognitive model attributes a fundamental role to the negative evaluation of tinnitus.

Clinical trials in which this model is applied to treatment, by which the clinical relevance of the model can be tested, have not taken place yet. However, evidence exists that cognitive processes, such as interpretation, attention, and memory, are indeed involved in chronic tinnitus suffering (Andersson et al. 2013; Conrad et al. 2011; Rossiter et al. 2006; Stevens et al. 2007), though these studies were not specifically aimed at validating the model.

8.4 The Cognitive Behavioral Approach

Several so-called “cognitive behavioral” accounts for tinnitus have been postulated (Cima et al. 2011a; Hallam et al. 1984; Kleinstauber et al. 2012; McKenna et al. 2014). A promising one is based on a fear-avoidance model (FA model) of chronic pain (Vlaeyen and Linton 2000, 2012), since in this model, predictions about the behavioral components in the maintenance of tinnitus distress are included. The FA model (Fig. 8.3) for chronic tinnitus offers explanatory predictions about both the cognitive processes and the behavioral mechanisms. It predicts that individuals perceiving the tinnitus signal are subject to automatic emotional and sympathetic responses. These symptoms are misinterpreted as harmful or threatening. If the signal persists, the coinciding threatening (alarm) states, which indicate malignance of the signal, elicit conditioned, both classical and operant, fear responses, i.e., fear, increased attention, and safety seeking, i.e., avoidance and escape behaviors. These safety behaviors become negatively reinforced through instant decreased fear, which is adaptive in the acute phase. In other words, by avoiding, or not exposing themselves to tinnitus-related perceptions, patients learn that their fear instantly diminishes. However, in the long run, through persistent avoidance of tinnitus percept as well as tinnitus-eliciting or tinnitus-increasing stimuli, the heightened fear and fear responses, such as hypervigilance and safety seeking, are maintained. Avoidance behaviors subsequently lead to task interference and functional disability (Blaesing and Kroener-Herwig 2012; Hesser et al. 2009). The maintained high threat value of the tinnitus leads to increased tinnitus severity and distress, feeding into an endless circle of increased disability (Cima et al. 2011b).

Fig. 8.3
The fear-avoidance model

The cognitive behavioral model predicts that the tinnitus signal invokes automatic sympathetic and emotional responses, which are misinterpreted as harmful or threatening, leading to safety behaviors.

A typical feature of the FA model is its prediction; next to the maladaptive pathway (leftward), an alternative and more adaptive pathway (turning right) is proposed, whereby a positive or neutral evaluation of the tinnitus results in no or low fear of the tinnitus and in partially or completely decreased distress. In other words, the tinnitus sound is accepted by the system as being benign; therefore, no unwanted attentional resources are needed. In turn, avoidance and/or escape behaviors do not interfere with daily tasks, resulting in lack of severe disability due to tinnitus.

Accumulating evidence indicates that a cognitive behavioral treatment, based on this fear-avoidance notion, which targets reappraisal of and exposure to the tinnitus sound, significantly reduces tinnitus distress as well as tinnitus suffering and improves the quality of life and daily functioning of tinnitus patients (Andersson 2002; Andersson and Lyttkens 1999; Andersson et al. 2002; Cima et al. 2012; H. Hesser et al. 2011; Hoare et al. 2011; Martinez-Devesa et al. 2010). However, the cause-effect relationships of specific learning mechanisms are still unknown (Cima et al. 2011a; J. A. Henry et al. 2005a; Kleinstauber et al. 2012).

8.5 Comparing the Models

In overview, consensus among the theoretical models exists regarding the evidence that a neutral acoustic signal receives negative valence by means of classical conditioning, in which an individual learns that the signal becomes predictive for negative states (“false alarms”) as a result of automatic negative responses elicited by this signal (Pawel J. Jastreboff and Jastreboff 2006; Vlaeyen and Linton 2000). Both cognitive models highlight the importance of cognitive processes, and although behavioral consequences are mentioned and recognized as important, they are considered secondary for the maintenance and therefore also for the treatment of chronic tinnitus suffering. Conscious cognitive processes are emphasized, as these constitute the main therapeutic targets in treatments stemming from these models, hypothesizing that the classical (involuntary) learning mechanisms are of lesser importance.

Following the lines of theoretical reasoning, it can be postulated that conditioned negative responses are the main cause of the suffering (Jastreboff and Jastreboff 2006) and that these aversive responses toward the tinnitus sound lead to misinterpretations feeding back into negative evaluations and fear responses (Hallam et al. 1988; Hallam et al. 1984; P. J. Jastreboff 2007; McKenna et al. 2014). Building on these principles, the FA model offers predictions about fearful responses (emotional and attentional) and behaviors (Cima et al. 2011a), which explain the maintained tinnitus distress. This latter premise is based on an operant component in learning theory terms and remains unexplained, though mentioned, both in the neurophysiological model as well as the cognitive model. The FA model provides specific predictions on this level, which leads us to the main difference between the models.

While the NP model deals mainly with tinnitus generation and detection and the habituation and cognitive models emphasize the voluntary conscious processing of the tinnitus, the FA model is predictive beyond that and picks up there where the other models stop being explanatory. The main conceptual overlap might lie at the level of the detection/perception and interpretation level, and the classical learning principles are involved purportedly, as was described above. The models differ in explaining how these learning principles—both classical and specifically the operant learning mechanisms—may play a role. The NP model is mainly based on neurophysiological processes and attempts to explain the psychological path in neurophysiological terms. This provides only general descriptions of classical and operant conditioning mechanisms. The habituation and cognitive models both state that the conscious alteration of negative interpretations will decrease arousal and distress as a result of tinnitus, with less emphasis on the behavioral processes. As opposed to this, the FA model is based on associative learning and operant principles and offers explanatory predictions about the classical and the behavioral mechanisms. This fear-avoidance approach integrates previous concepts and might prove helpful in discovering new venues of investigations, as well as in offering means to determine why not only cognitive but also behavioral treatment approaches are repeatedly found to be successful (Tutorial 8.1).

Tutorial 8.1 Theoretical models

Theoretical models leading to psychological treatment approaches for tinnitus distress can be roughly divided into two categories: the cognitive approaches and the cognitive behavioral approaches

Cognitive approaches

Neurophysiological model

Main hypothesis

Dysfunction is hypothesized on the following levels

 • Detection

 • Perception/evaluation

Based on two fundamentals of brain functioning in general

 1. Plasticity

 2. Habituation

Hallam’s habituation model

Main hypothesis

Malfunctioning attentional processes disturb habituation

McKenna’s cognitive model

Main hypothesis

Cognitive appraisal of the tinnitus signal and selective attention distort the tinnitus perception

Cognitive behavioral approaches

Fear-avoidance model

Main hypothesis

Safety behaviors, negatively reinforced in the short term (instant temporary decrease in fear), maintain tinnitus complaints (maintenance of underlying fear)

8.6 Treatment Approaches for Tinnitus-Related Distress

Next to the theoretical frameworks, a short overview of developments within the cognitive behavioral therapies (CBT) during the past decades is necessary, to provide the background for the development of treatments for reducing tinnitus-related distress. To answer the question as to what is meant by the cognitive behavioral therapies, we will take a short journey in the past.

8.6.1 The History of CBT

The first wave of CBT, or the first revolution, started with Wundt’s (1832–1920) experimental methods and findings, in combination with the emergence of the behavioral traditions of the classical- or respondent- (Pavlov 1927) and operant- or instrumental- (Skinner 1938) conditioning principles. A class of psychological interventions emerged and converged theory, evidence, and experimental methods. Noteworthy is that at that time, it was a new and a very exciting field in psychology.

A second major impulse was given by the so-called cognitive revolution (second wave), not surprisingly by cognitive sciences and entailed the empirical study of how the thinking (cognitions) and the interpretations (attributions) affected the emotions and behavior. Methods were mainly aimed at the conscious and voluntary altering of interpretations and thought processes, by means of elaborate narrative therapeutic methods (cognitive therapy). Examples include rational emotive therapy (RET) introduced by Albert Ellis in the 1950s, which focused on the associations between cognitions and emotions (Ellis and Grieger 1977). Aaron Beck (1976) introduced cognitive therapy (CT) for the identification and modification of thought “errors” (Gopinath et al. 2010). Another major influence on the cognitive revolution was the major discoveries in computer science and programming, where a computer software gave almost a perfect analogy for understanding the “programming rules” in human brains. During the early 1970s, the behavioral and cognitive approaches merged (Dobson 2010; Hofmann et al. 2012), and the term “integrated cognitive behavior therapies” (CBT) was invented.

The new CBT treatments, such as mindfulness-based stress reduction (MBSR), or simply mindfulness, and acceptance and commitment therapy (ACT), have been classified as “third-wave” CBT approaches (Dobson 2010; Hayes 2004). Some discussion exists as whether they are a new form of therapy altogether, or whether they are still grounded within the traditional CBT family (Ost 2008). For the purpose of this chapter, they will be considered the third revolution in CBT. Although the third-wave CBT treatments contrast with the cognitive tradition by accepting the existence of negative thoughts and emotions rather than trying to modify them, a major similarity is the assumption that human suffering is caused by learning, dysfunctional beliefs, and behavior, all leading to emotional distress and disability. Effects of both ACT and MBSR have been investigated in different populations, including patients with different psychological disorders (e.g., anxiety and depression), with chronic symptoms (e.g., chronic fatigue and chronic pain), and in the healthy population (Bohlmeijer et al. 2010; Powers et al. 2009; Veehof et al. 2011).

The cognitive behavioral therapies (first, second, and third wave) share the idea about psychological distress and resulting problems being based in malfunctioning information processing, emotional reactivity, and behavioral mechanisms. CBT has led to a plethora of evidence-based cognitive behavioral treatments for mental and somatic health disorders (Hofmann et al. 2012). In sum, CBT is an integrative and pragmatic treatment approach aimed at modifying dysfunctional behaviors and beliefs in order to reduce symptoms, increase daily life functioning, and ultimately recover from the disorder (Dobson 2010).

8.6.2 Tinnitus Retraining Therapy

Although tinnitus retraining therapy (TRT) is not usually categorized as a form of CBT, it is nevertheless a treatment with a main cognitive component and is therefore at least in part a form of firstwave CBT.

As was introduced earlier, TRT is the implementation of the NP model, which is a theory of neurophysiological processes considered to be relevant for tinnitus perception. TRT is based on two fundamental principles of brain functioning: (1) plasticity and (2) habituation. The basis of the NP model is that the actual source (the tinnitus sound) is not causing the annoyance, but it is the subjective experience and interpretation of the individual which determine whether the tinnitus is experienced as aversive or not.

Two main components make up TRT. The first component is a form of cognitive therapy, so-called retraining counselling or teaching. Through verbal instruction patients are expected to reinterpret the tinnitus, thereby decreasing negative thoughts and beliefs about the tinnitus. The second entails sound therapy, which is either instructing the patient to wear tinnitus maskers1 or to enrich sound environment, avoiding silence at all costs. It is hypothesized that sound therapy (and avoidance of silence) will decrease the detection of tinnitus and therefore facilitate sustained habituation (Jastreboff and Jastreboff 2000). Changes in tinnitus interpretation and evaluation are postulated to be generated automatically by instruction and sound enrichment. The resulting emotional and behavioral consequences are not the aim of therapy, nor are there specific predictions about these in the NP model. Additionally, TRT postulates that once the conditioned associations are removed, by said interventions, habituation should occur (Jastreboff and Hazell 2008). Although there is a specific prediction about what is the unconditioned stimulus, the conditioned stimulus and conditioned responses are not clearly specified in the NP model (Cima 2013). The effectiveness of TRT remains inconclusive (Hoare et al. 2011; Hobson et al. 2010; Phillips and McFerran 2010), though TRT, and specifically the use of sound generators, is still a popular form of treatment for tinnitus distress, mainly among audiologists.

8.6.3 Cognitive Therapy and Cognitive Behavioral Therapy

Confusion often exists about the differences between cognitive and cognitive behavioral therapy (CBT), since both terms are used interchangeably. Since CBT stems from the convergence of two distinct theoretical schools, the radical behavioral school (first wave) and the cognitive school (second wave), CBT entails a diversity of both cognitive and behavioral principles and methods, and usually a combination of these is used in therapeutic sessions. Therefore, both cognitive and behavioral treatment elements can be found when reviewing CBT procedures in general as well as in tinnitus intervention. Cognitive behavioral theory and treatment has been applied in tinnitus research for decades (Hallam et al. 1988; Scott et al. 1985; Sweetow 1986), and CBT approaches for tinnitus have been repeatedly shown to be effective in decreasing tinnitus distress, anxiety, and tinnitus annoyance and improving daily life functioning. Although there are the discernible common elements across CBT-based treatments for tinnitus, the investigated tinnitus CBT approaches vary in numbers of treatment sessions, hours spent in therapy, group versus individual formats, face-to-face versus internet based self-help therapies, combinations of different treatment elements, and tinnitus diagnostics and outcome assessments.

8.6.4 The Cognitive Approach

In line with the evolution of CBT in general, during the development in CBT for tinnitus, cognitive therapeutic procedures have been applied plentifully. The main idea of the cognitive approach is that psychological distress is maintained by cognitive factors. Typical cognitive therapeutic interventions (or so-called “talking” therapy) are aimed at (Ellis and Grieger 1977; Beck 1976):

  1. 1.

    Correcting/changing “erroneous” beliefs or thought processes (cognitions)

  2. 2.

    Dealing with current problems and thought processes (and not so much with the past)

  3. 3.

    Advising the patients to perform behavioral experiments in order to test the validity of maladaptive thoughts and beliefs

In line with the cognitive tradition, the cognitive model (McKenna et al. 2014) postulates that therapeutic strategies used to change maladaptive cognitions lead to automatic changes in emotional distress and in problematic behaviors. These cognitive techniques seem to be helpful in the short term. Techniques, next to educational counselling, include but are not limited to “Socratic dialog,” thought control, rational thought formulation, exploring automatic thoughts, and testing of thoughts and beliefs through behavioral experiments.

8.6.5 A Fear-Avoidance Approach

Recently, exposure therapy, which is a behavioral therapeutic strategy, entered CBT treatment protocols for tinnitus (Cima et al. 2012), next to the much more known cognitive (“talking”) interventions. Exposure therapy, also applied in chronic pain CBT treatments (Volders et al. 2011), is a clinical application of what is called “extinction” of the association between two stimuli in classical terms of learning theory. It is assumed that tinnitus patients learned to be fearful of the tinnitus percept. That is, in the distressed tinnitus patients, the initially neutral tinnitus signal became associated with sympathetic arousal (alarm detection) (Jastreboff 1990; Wilson 2006). According to fear-avoidance reasoning (see Fig. 8.4), the neutral tinnitus signal (CS) became a predictor of aversive interoceptive stimuli (US), hereby receiving a very negative value (danger). Patients interpret the signal as a sign of harm or injury, which is why they are so fearful, selectively single out the tinnitus signal, are interrupted, and engage in safety-seeking behavior (CR). These mechanisms are likewise at work in arachnophobias, for example. The spider, which is harmless, becomes a sign of great danger, leading to the extreme fear.

Fig. 8.4
A new fear-learning paradigm: applying the classical conditioning to tinnitus-related distress (Cima 2013)

For arachnophobia, exposure procedures consist of repeated confrontations with spider-related images, objects, and eventually real spiders, which evoke the greatest fear in the patient. As a result of repeated exposure to the most feared stimuli, the patient learns that confrontation with spiders is not life-threatening, and therefore they are not in danger. In the end, the fear of spiders dissipates (extinction). Analogically speaking, tinnitus patient is extremely fearful of perceiving the tinnitus. Even though the tinnitus is continuously present, the involuntary response is to not hear it and to try to be minimally confronted with the tinnitus sound (avoidance). Patients do this by trying to control sound environment, or not thinking about tinnitus (which is contradictory: “white bear effect”), and direct their attention elsewhere, but consequently they increase the monitoring and awareness of tinnitus. Cognitive resources by consequence are depleted, leading to task interruptions, more avoidance (safety seeking), and eventually disruptions in functional activities. The sustained consequences are severe disabilities disrupting all life domains and severe dysphoria (dissatisfaction with life).

This “new” form of CBT for tinnitus typically includes the third-wave forms of therapy (see Tutorial 8.2) to enhance internal observations, to increase moment-to-moment consciousness (exposure to) of the tinnitus, and to provide the ability of observing tinnitus-related emotions, sensations, and cognitions in a nonjudgmental way. Exposure therapy for tinnitus patients involves exposing them to their tinnitus sound, the interceptive sensations associated with the tinnitus, as well as their moment-to-moment narrative. In order to provide an appropriate context, exposure is performed in quiet circumstances. This way, the patient experiences that the tinnitus sound is harmless, not dangerous, and listening to it in silent environments will not have catastrophic consequences. They also learn that the aversive interoceptive stimuli are not always triggered and threat expectancies are adjusted. These experiences lead to a neutralization of tinnitus by extinction of tinnitus-related fears; consequently the more the tinnitus becomes less intrusive and bothersome, the more they engage in exposure. In classical learning theory terms, if the patients are exposed to the conditioned stimulus, without the unconditioned stimulus always occurring, extinction of the unwanted conditioned responses occurs (see Fig. 8.4).

8.6.6 Comparing the Treatments

As has been stated before, the theoretical frameworks are fundamentally based on the idea that the initially neutral tinnitus signal receives an “alarm” value, through classical conditioning. In turn, this negative tinnitus valence exacerbates negative responses in cognitions, emotions, and behaviors, hindering the “normal” process of habituation. Tinnitus distress—which is the very negative and aversive state—arises when processes of adaptation and the efforts to that have failed to return the organism to equilibrium or homeostasis.

Important to note is that the treatment avenues have been contradictory. The TRT approach suggests that next to extensive education, a (partial) masking of the signal (avoidance of the signal, by avoiding silence at all costs) is the road to habituation. The habituation model and cognitive approaches reason that thought control and attention diversion techniques (altering thoughts/beliefs about the tinnitus and actively directing attention away from the tinnitus) will be beneficial for habituation. For a short-term habituation, these strategies might be useful.

On the other hand, the FA approach leads to the complete opposite approach. The FA’s main aim is extinction of CS-US associations and therefore sustained extinction of conditioned responses, instead of enforcing short-term habituation. If we look at Fig. 8.4, the FA approach aims at dissolving the dotted arrow between the CS and US.

Tutorial 8.2 The “third-wave” CBT treatments

Mindfulness-based stress reduction (MBSR)

Mindfulness is a type of psychological treatment aimed at psychological distress, depressive symptoms and anxiety, initially developed for individuals suffering from chronic disease. MBSR was developed by Kabat-Zinn (1982), Ludwig and Kabat-Zinn (2008). MBSR protocols typically consist of up to 10 group sessions. The focus lies on training of the skill of being mindful, which is a moment-to-moment awareness, and observing emotions, sensations, and cognitions nonjudgmentally. Sessions are built up around meditational skills, bodily exercises, and psycho-education. Initially MBSR was developed for chronic pain sufferers and later adapted for chronic diseases such as heart disease and recently for tinnitus as well (Bohlmeijer et al. 2010; Kauth et al. 2010; Philippot et al. 2012). As a stand-alone treatment approach, mindfulness has been applied to a large number of psychological disorders (Fjorback et al. 2011; Shapiro et al. 2011). Mindfulness is also an important component of other psychological treatments such as ACT, some forms of behavioral treatment, and cognitive therapy (Hayes et al. 1999, 2006; Teasdale et al. 2001)

Acceptance and commitment therapy (ACT)

According to its founder (Hayes et al. 2006), ACT has its roots in the behavioral tradition. Interestingly, ACT does not emphasize the accuracy or the content validity of cognitions and behaviors, as is the case in the more cognitive approaches, described earlier. Focus in ACT lies on functional usefulness of thoughts and actions and not on the “right- or wrongfulness” (Hayes et al. 2006; Hofmann et al. 2010). One of the key elements of ACT is to decrease “experiential avoidance” (Hayes and Wilson 1994); i.e., ACT advocates experiencing psychological events (thoughts, perceptions, emotions) in a nonjudgmental way, not trying to change or modify those events, leading to a more functional awareness of how thoughts, emotions, and behaviors create and maintain distress. Since MBSR approaches advocate present moment awareness and observation in a nonjudgmental way, which results in decreased rumination and worry, it has been an integrated part of the ACT protocol

In other words, the FA model contradicts the habituation approaches by predicting that doing the exact opposite (confrontation instead of avoidance, exposure instead of masking, tinnitus awareness instead of attention diversion, observing thoughts/beliefs instead of altering/challenging) will lead to sustained recovery of distress. Indeed, strong associations between avoidance behaviors and perceived tinnitus handicap have already been found (Kleinstauber et al. 2013).

Implementing the new concepts in CBT, using mindfulness-based exercises as well as ACT methodology (see Tutorial 8.2) for exposure toward tinnitus, has indeed proven successful in effectively decreasing tinnitus-related distress (Cima et al. 2012; Hesser et al. 2012, 2014; Philippot et al. 2012; Westin et al. 2011).

8.7 Measuring Tinnitus-Related Distress

As it has been described in the previous sections of this chapter, distress is an aversive state, which is the result of the organism failing to adapt to stressors. Tinnitus-related distress, and the treatment thereof, hardly focusses on the tinnitus sound itself, since indeed emotional distress is the main and the most significant factor in predicting the variability in quality of life of tinnitus patients is psychological distress (Cima et al. 2011a, b; Erlandsson and Hallberg 2000). In individuals with persistent tinnitus, the acoustic characteristics of tinnitus percept (e.g., loudness or pitch) are hardly associated with tinnitus severity or treatment outcome (Jastreboff 1990; Jastreboff and Hazell 1993). The initial negative evaluation and subsequent fear responses leading to the overall distress might be more relevant in defining the severity of complaints than the tinnitus percept itself.

Accumulating evidence suggests that fear responses, cognitive misinterpretations, negative emotional reactivity, attentional processes, and misappropriated behavioral strategies are crucial in dysfunctional habituation leading to severe tinnitus-related distress (Andersson and McKenna 2006; Erlandsson and Hallberg 2000; Kroner-Herwig et al. 2003; Zachriat and Kroner-Herwig 2004). In other chronic disorders, like irritable bowel syndrome, chronic fatigue syndrome (Deary et al. 2007), and chronic pain disorder (Gatchel et al. 2007), psychological mechanisms, predicting or promoting dysfunctional responses to symptoms, have similarly shown to be significant predictors of suffering (Crombez et al. 1999; Rief and Broadbent 2007).

8.7.1 Tinnitus Severity in Terms of Distress

Tinnitus severity can be defined as a function of the level of averseness of the state tinnitus patients are in, in other words, the level of distress. As mentioned earlier, only for a small group of patients (3–8%), tinnitus is distressing and therefore disabling (Davis and Refaie 2000; Ahmad and Seidman 2004). Since distress is a term which coins the general aversive state, instruments to measure this construct usually include subdomains, which are hypothesized to be of importance for tinnitus severity. These instruments are therefore hybrid in that they measure several concepts as a means to capture tinnitus distress. There are several instruments in use for assessing the level of severity of tinnitus complaints. In a review on disease-specific health-related quality of life (HR-QoL) instruments used to measure outcomes in tinnitus trials, six commonly used HR-QoL tinnitus instruments were identified (Kamalski et al. 2010; Meikle et al. 2007) and will be shortly described below. The instruments specifically used to measure the outcome of treatment are described in Chap. 9.

The Tinnitus Handicap Inventory (THI) (Newman et al. 1996) is an instrument that presumably measures the impact of tinnitus on a daily life. It has three subscales, functional, emotional, and catastrophic responses to the tinnitus, the second being psychological distress related. Both overall and subscale internal consistency were found to be good. The Tinnitus Questionnaire (TQ) (Hallam et al. 2004) has six predominantly distress-related domains: emotional distress, cognitive distress, intrusiveness, auditory and perceptual difficulties, sleep disturbances, and somatic complaints as a result of the tinnitus. The TQ items are internally consistent; however, the subscales lack internal consistency. The Tinnitus Reaction Questionnaire (TRQ) (Wilson et al. 1991) was intended to specifically measures distress related to tinnitus. TRQ incorporates four different domains: general distress, interference, severity, and avoidance of the tinnitus. The three questionnaires focus mainly on measuring patient’s perception, on impaired individual functioning, or on specific functions as a result of tinnitus.

The Tinnitus Severity Index (TSI) (M.B. Meikle et al. 1995) was introduced as a unified measure of tinnitus severity. Two items specifically address the interference of the tinnitus in daily life activities. The Tinnitus Handicap Questionnaire (THQ) (Kuk et al. 1990; Meikle et al. 1995) was intended to measure patient’s perceived degree of handicap due to tinnitus. The THQ has three domains: physical health/emotional status/social consequences, hearing and communication, and personal viewpoint on tinnitus. Seven items specifically address the interference of tinnitus on the daily activities: four of them address hearing difficulties, two address social interactions, and one item addresses sleep difficulties due to tinnitus. The THQ subscales fails on internal consistency.

The Tinnitus Severity Questionnaire (TSQ) (Coles et al. 1991) is a short unified measure, with two items specifically addressing interference of tinnitus, one item regarding sleeping habits and one the impairment of concentration.

More recently, the Tinnitus Functional Index (TFI) was introduced as a new measure for scaling the severity and negative impact of tinnitus, both for use in diagnostic assessment and for measuring treatment-related changes in tinnitus (responsiveness) (M. B. Meikle et al. 2012; Henry et al. 2014). What is unique about this instrument is that it is a measure of tinnitus severity as perceived “over the last week,” therefore asking patients to reflect about only a short timeframe (1 week). The TFI is also a hybrid, measuring tinnitus-related distress/severity as a function of predominantly psychological construct such as attention, worry, anxiety, and depression as well as the more functional constructs such as hearing, social life, and activity level. Table 8.1 lists these seven instruments along with their characteristics and psychometric quality.

Table 8.1
Characteristics and psychometrics of existing tinnitus HR-QoL instruments

Construct validity

Reliability (test-retest)

Tinnitus Handicap Inventory (THI)

(0) Never

(2) Sometimes

(4) Yes

Functional, emotional, catastrophic responses

Tinnitus Questionnaire (TQ)

Partly true

Not true

Subscales not reliably tested, therefore invalid

Emotional distress, cognitive distress, intrusiveness, auditory perceptual difficulties, sleep disturbance, somatic complaints

Tinnitus Reaction Questionnaire (TRQ)

(0) Not at all

(4) Almost

General distress, interference, severity, avoidance

Tinnitus Severity Index (TSI)

(0) Never

(4) Always

Tinnitus Handicap Questionnaire (THQ)

(0) Strongly

(100) Strongly agree

Physical health/emotional Status/social consequences, hearing and communication, personal viewpoint

Tinnitus Severity Questionnaire (TSQ)

(0) Not affected

(4) Always affected

Tinnitus Functional Index (TSQ)

Oct 20, 2017 | Posted by in OTOLARYNGOLOGY | Comments Off on Stress-Related Tinnitus Treatment Protocols
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Inheritance tax: Four in five over-55s at risk of brutal death bills

Rising property prices, on top of increased pension wealth, mean the baby boomer generation is in a position to pass on significant assets to their loved ones.

Estates liable for inheritance tax face an average bill of nearly £175,000 each, according to pension provider Prudential.

Yet, less than a fifth of over 55s have taken action to reduce liability – despite death tax being one of the easiest taxes to legally avoid.

Setting up trusts, gifting assets and taking out life insurance are just a few of the ways to limit the impact of the dreaded duty.

But fewer than one in 10 are seeking financial advice, making gifts to family members or establishing trusts, showed the study.

It comes as three-quarters said they want some control over how the inheritance is spent, with a third wanting to make sure grandchildren benefit.

Les Cameron, tax expert at Prudential, said: “Record house prices are one reason why inheritance tax receipts are rising fast.

“In 2012/13 fewer than 18,000 estates had an IHT bill but the Government says that there will be 41,000 taxpaying estates in 2015/16 and that IHT receipts will hit £6.2bn by 2021/22.

“Reducing inheritance tax bills is relatively straightforward.”

Mr Cameron added: “People need to strike the right balance between giving their wealth away during their lifetime to reduce the size of their estate, and maintaining some form of control after their death over who can access it and when.

“To help ensure efficient inheritance tax planning, obtaining financial and legal advice should be money well spent.”

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Research on Nerve Cell Circuitry Reveals Clue about Schizophrenia

October 28, 2004

WINSTON-SALEM, N.C. – Animal research at Wake Forest University Baptist Medical Center has found how one of the genes linked to schizophrenia might function to cause the disease. The work was reported today at the annual meeting of the Society for Neuroscience in San Diego.

“Our research in mice suggests that defects in a gene may interfere with communication between nerve cells in the brain,” said Ashok Hegde, Ph.D. “We believe this may cause a common symptom of schizophrenia – being unable to filter out unimportant sensory information.”

Schizophrenia tends to run in families and has been linked to several different genes. Hegde and colleagues studied RGS4, a gene that is believed to control the release of neurotransmitters, the molecules that help nerve cells communicate with each other. Recent studies in humans show that less of the protein produced by the RGS4 gene is found in the brains of patients with schizophrenia.

“Through our research on mouse brain nerve cell circuitry, we have shown that this gene can control communication between nerve cells in the brain,” said Hegde, assistant professor of neurobiology and anatomy. “Our ultimate goal is to better understand the cause of schizophrenia and to help in developing more effective drug treatments.”

Hegde and colleagues studied a part of the mouse brain that has two major types of nerve cells similar to the nerve cells that malfunction in people suffering from schizophrenia. One type of cell gets excited and sends signals to other nerve cells. The other type blocks such signals. The cells that block signals are important in controlling how much communication takes place between nerve cells.

In normal people, the signal-blocking nerve cells act as gatekeepers. They promote communication only if the information from outside is strong enough or relevant enough. Scientists believe that in schizophrenia patients, the signal-blocking cells are weak.

“The excited cells do not listen to the signal-blocking nerve cells and chatter whether the news from the outside world is important or not,” said Hegde. “So, people with schizophrenia may respond to every little thing that hits their senses, such as slight noise in the background.”

To test their hypothesis that RGS4 is involved in brain signaling, Hegde and colleagues injected the RGS4 protein in a nerve cell and measured “calcium current,” a marker for the levels of neurotransmitters released by nerve cells. They found that the protein increased levels of neurotransmitter, suggesting that RGS4 helps nerve cells communicate better with each other.

Their study of nerve cell circuitry is a new approach to learning about schizophrenia.

“We believe this can tell us a lot about how defects in genes might cause schizophrenia,” said Hegde. “Our next step will be to see if defects in RGS4 can actually cause schizophrenia-like symptoms.”

They plan to study a simple behavior: the startle response to a loud noise. Normal people are startled when they hear a loud noise. On the other hand, if normal people first hear a not-so-loud noise followed by a loud noise, they are not startled as much as by the loud noise alone. In people with schizophrenia, the startle response is abnormal – they are startled by the loud noise even if they hear a not-so-loud noise first.

Mice and rats have responses similar to normal people. The researchers will study mice to see if a shortage of RGS4 causes an abnormal startle response and schizophrenia-like symptoms.

Schizophrenia is a devastating mental illness that affects about 2 million Americans in a year. Worldwide, 1 percent of the population suffers from schizophrenia. The most common symptoms of schizophrenia are delusions and hallucinations. People suffering from schizophrenia lose the ability to think properly and cannot tell what is important from unimportant information in their surroundings.

The research team led by Hegde included Lan Ding, Ph.D., and Chenghai Dong, Ph.D., from the Department of Neurobiology and Anatomy.

Media Relations


Dosage mistake causes baby brain damage, hospital settles for $7M

In a recent post, we wrote about how hard limits on IV pumps can prevent medication errors. But even hard limits cannot prevent a dosage mistake if an adult pump is used on an infant while being treated at a Pittsburgh hospital. It is imperative to use the proper equipment for the proper purpose to prevent patients from suffering a serious injury. A medical malpractice suit that was recently settled in Illinois is a prime example of this.

The family of a girl who suffered brain damage after her birth in 2003 because of a dosage mistake will receive $7 million from the hospital at fault. The hospital did not use a neonatal IV pump to administer fluids to the newborn, but rather an IV pump intended for adults. Medical professionals did not program any soft or hard limits on the pump either. As a result, the newborn girl received 405 cc per hour rather than the intended 4.5 cc per hour. The dosage mistake was not noticed until 46 minutes later. By then, her blood volume had increased by 250 percent, her weight increased by 20 percent and she had sustained brain damage. Now, 10 years later, the girl has developmental delays and requires special education.

Medication errors can happen for any number of reasons.  Whether the dosage mistake is a result of a negligent nurse, a pharmacists failure to read doctor’s handwriting properly or something else, it can have devastating effects. Anyone who has suffered a serious injury from a medication error may want to speak with an attorney.

Source:, “Edward Hospital settles baby overdose suit for $7 million,” Sun-Times Media Wire, Dec. 16, 2013.


07:33am Wednesday 26 September 2018

To smoke or not to smoke?

As part of a project on “Theory and Empirics of Cigarette Consumption”, financed by the Deutsche Forschungsgemeinschaft (DFG), LMU sociologists have been looking for answers to the question of why people start to smoke in general. “Most previous investigations have focused on the role of the social context”, says LMU sociologist Thomas Wimmer. “And, in a nutshell, the results of these studies merely provide us with the following explanation: Peter smokes because his best friend Paul smokes, and Paul smokes because his parents smoke, and Paul’s parents began smoking because their best friends have already been smoking.” The principle of imitation as an explanation ultimately involves a circular argument, thus LMU-researchers have begun to use a different approach that concentrates more on ascertaining the individual’s reasons for smoking. The basic assumption here is that smoking is a behavior that typically begins during adolescence, and is – in principle – potentially attractive to all young persons. In this scenario, whether or not a person actually takes up smoking depends on how he or she assesses the costs involved. These costs include not only the financial costs of the behavior itself, i.e. the price of cigarettes, but also other consequences, for example, losing the parent´s appreciation when an adolescent decides to ignore the advice not to smoke. “More restrictive laws on smoking in public would in itself raise the social cost of the behavior, simply by making it much more difficult for smokers to indulge in the habit.”

The basic premise of the recent study is the plain assumption that cigarette smoking is an activity that is characteristic of adolescence and, as such, is attractive for virtually all youngsters. If this is the case, then one must inquire into the factors that determine whether or not a given individual takes up or gives up the habit. “There are several factors that play a role in the decision to take up smoking which we can define as costs“, says Wimmer. “First of all, there are financial costs associated with smoking. How much money one can afford to spend on cigarettes will, in the first place, determine just how easy it is for a person to begin smoking and to sustain the habit.” But the price of cigarettes is not the only relevant cost to be considered. The attitude of one’s parents to smoking is also an important factor. If parents explicitly forbid their children to smoke, the costs increase, because each child must now take a deliberate decision to ignore that prohibition. How long one remains among the ranks of smokers, on the other hand, depends on the degree of addiction, concern for health effects and the attitude of one’s partner to smoking.“

In the realm of human behavior, no single size will ever fit all. But it turns out that a model based on the considerations sketched out above can correctly predict whether or not a young person will take up smoking in about 80% of the cases. The LMU researchers interpret this result as convincing evidence for the explanatory power of their model. As Wimmer emphasizes, “More restrictive laws on smoking in public would add another factor to the calculation – on the negative side. However, forecasting the effects of such a ban is fraught with difficulties, because we are dealing with social behavior. A legally binding ban that affects everyone could bias attitudes and behavior in a very different way than the disapproval of single persons“ (suwe)

Dipl. Soz. Thomas Wimmer
Department of Sociology
Ludwig-Maximilians-Universität (LMU) München
Phone: +49 (0) 89 / 2180 – 3256
E-mail: wimmer@soziologie.uni-muenchen.de

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Acknowledge - method of object PmAlarmEventItem

Alarm item acknowledgement.
Acknowledge([sUserNote As String], [tTimeAck As Date], [sExtra As String])
oAlEvItem.Acknowledge sUserNote, tTimeAck
sUserNote[optional] (String) The text note that is stored to the data together with the acknowledged alarm/event item (it is enabled on the Storage page).
tTimeAck[optional] (Date) The acknowledge time of the alarm. If not set, then the computer current time is used.
sExtra[optional] (String) Additional parameters parameters.

Entries are in format KeyVal, for example "ackerid:operator1;lang:en;".

"ackerid:xx;" - Identifier of user that acknowledged the alarm. This identifier is defined in the AckerId property of the corresponding alarm and will also be written to disk into the AckerId column (if this column is enabled for writing to disc). If the parameter is not entered, then the identifier of user that acknowledged the alarm is used (local user or network user). For example"ackerid:operator1;".
"lang:xx;" - Specifies national language for Macro expression $.text. Language is determined with a text identifier, e.g. "en", "de", "ru" etc. - see Fully supported languages in the PROMOTIC system. If not set, then the present language of running application is used instead. This is relevant for multiple acknowledgement with filtration string switched on (e.g. $all;area:boiler1;), where it is possible to set the language for evaluation of localized fields. For example"lang:en;".
The acknowledgement succeeds only when the local user has the permission Acknowledge.

Calling the Acknowledge method over the acknowledged alarm has no effect. An unacknowledged alarm is acknowledged. The behaviour of the alarm during the acknowledgement is specified by the Acknowledge type configurator. The acknowledgement of the alarm is usually done interactively by the user from the viewer of an alarm group.

It is irrelevant for events (relevant only for alarms).

VBScriptSelect and copy to clipboard

Dim oAlItem
Set oAlItem = oAlEv.Item("Temperature")
oAlItem.Acknowledge "UserNote"

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The project implements the queuing system in java. It creates an interface through which the performance measures of the various queuing models are calculated.

The interface implements three kinds of queuing system namely: Single Server, Multi Server, Infinite Server .It inputs various kinds of information from the user like the nature of system capacity, number of servers, system capacity, variance, arrival rate, service rate , inter arrival time , service time and outputs system utilization , average number of customers in the system , average number of customers in the queue , average waiting time in the system , average waiting time in queue .

A queuing system consists of one or more servers that provide service of some sort to arriving customers. Customers who arrive to find all servers busy generally join one or more queues (lines) in front of the servers, hence the name queuing systems. There are several everyday examples that can be described as queuing systems, such as bank-teller service, computer systems, manufacturing systems, maintenance systems, communications systems and so on.

.Arrival process . let Si be the service time of the ith customer.Components of a Queuing System: A queuing system is characterised by three components: . = 1/(E(A) the arrival frequency. The arrival process consists of describing how customers arrive to the system. Arrival Process Arrivals may originate from one or several sources referred to as the calling population.Queue discipline. An example of a limited calling population may be that of a fixed number of machines that fail randomly. If Ai is the interarrival time between the arrivals of the (i-1)th and ith customers. we shall denote the mean (or expected) inter-arrival time by E(A) and call it ( ).Service mechanism . Service Mechanism The service mechanism of a queuing system is specified by the number of servers (denoted by s). we shall denote the mean service time of a customer by E(S) and µ = 1/(E(S) the service rate of a server. The calling population can be limited or 'unlimited'. each server having its own queue or a common queue and the probability distribution of customer's service time.

Commonly used queue disciplines are: FIFO .Queue Discipline Discipline of a queuing system means the rule that a server uses to choose the next customer from the queue (if any) when the server completes the service of the current customer. Similarly.Customers are served in order of their importance on the basis of their service requirements. Priority . Only some of these will be discussed here. of customers being served at t Then the measures.Customers are served in a last-in first-out manner. Let. LIFO . (if they exist) are called the steady state time average number in queue and the steady state time average number in . the measures. Measures of Performance for Queuing Systems: There are many possible measures of performance for queuing systems. (if they exist) are called the steady state average delay and the steady state average waiting time in the system. Di be the delay in queue of the ith customer Wi be the waiting time in the system of the ith customer = Di+ Si Q(t) be the number of customers in queue at time t L(t) be the number of customers in the system at time t = Q(t) + No.Customers are served on a first-in first-out basis.

. . .the system.the probability of turn-aways. service and queue and its discipline. A = Probability distribution of the arrivals B = Probability distribution of the departures . due to insufficient waiting accommodation.that probability that all service facilities will be idle. the queue system is usually described in shorten form by using these characteristics.the expected idle time of the total facility.the probability that any delay will occur. Since all queues are characterised by arrival.the probability that the total delay will be greater than some predetermined value . Notation for Queues. Among the most general and useful results of a queuing system are the conservation equations: Q = ( ) d and L = ( ) w These equations hold for every queuing system for which d and w exist. Another equation of considerable practical value is given by. w = d + E(S) Other performance measures are: . The general notation is: [A/B/s]:{d/e/f} Where.

Thus for example. infinite queue length.s = Number of servers (channels) d = The capacity of the queue(s) e = The size of the calling population f = Queue ranking rule (Ordering of the queue) There are some special notation that has been developed for various probability distributions describing the arrivals and departures. This queue system is also simply referred to as the M/M/1 queue. the [M/M/1]:{infinity/infinity/FCFS} system is one where the arrivals and departures are a Poisson distribution with a single server. Some examples are. calling population infinite and the queue discipline is FCFS. TECHNOLOGY TO BE USED Java Swing Components . M = Arrival or departure distribution that is a Poisson process E = Erlang distribution G = General distribution GI = General independent distribution. This is the simplest queue system that can be studied mathematically.

O Reilly Media. Queuing Theory for Telecommunications: Discrete Time Modeling of a Single Node System. . (2) Olivier Gallay. 2010. 2010. Agent-Based Routing in Queuing Systems: Self-Organization in Production and Service Networks: From Stylized Models to Application. Second Edition.BIBLIOGRAPHY (1) Attahiru Sule ALFA. (3) Java Swing .


The Fulham Focus 1974/75 FA Cup Run Quiz

To get you in the mood for the FA Cup 3rd Round against Southampton at Craven Cottage, Fulham Focus have put together a quiz on the 1974-75 FA Cup run. Let us know how you get on via Twitter!

Who scored first goal in the cup run in a 1-1 draw with Hull City?

Who scored most goals in the cup run, netting 6 times?

How many matches during the Cup run went to extra time?

Which of these players did NOT feature in every match of the Cup run?

Who was Nottingham Forest’s Manager at the start of our epic 4th round tie?

What colours shirts did Fulham wear in the quarter final win at Carlisle?

Les Strong sadly missed the final due to an injury sustained after the semi-final replay win. Who was he injured against?

How many of the 24 players (including subs) in the Final were not English?


4 Vacation Rental Options And Their Benefits

As you start to plan an upcoming vacation, you may be thinking ahead about the accommodation options that are available. You want to book a great place to stay so that you're comfortable and happy during the trip. There are many accommodation options to consider and they each have their own unique benefits. Keep reading to better understand what vacation rental options exist and what benefits they can offer you and your family:


Guide on Choosing Topics for Safety Talks

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However, some companies even hire safety Motivational Speakers to do this job. This is to ensure that all employees are oriented to the importance of creating and maintaining a safe workplace for everyone.

Things to Consider When Preparing for a Safety Talk

best to cover everything in 10-15 minutes.

Topic Relevance

  1. Tool and Equipment Safety. Through regular safety talk, you can discuss the safe use of one tool each session. Make sure though, that every tool is thoroughly explained to all employees. Although these employees have been trained to handle these pieces of equipment, it does not hurt to reiterate the importance of safety precautions.
    goggles within the site.
  3.  Weather-Related Precaution. There are jobs that involve working in extreme weather conditions such as the cold. Instead of having workers developed injuries, it is wiser to prevent this from happening by constantly reminding them of the importance of proper clothing to prevent frostbite and muscle strain.
  4.  Computer-related injuries. One of the common injuries in the office is carpal tunnel. Having a regular recap of proper posture in front of the computer can mitigate the development of the carpal tunnel. It is also helpful to give the employees tips on using the computer mouse effectively to keep it from having a carpal tunnel.
    changes must be communicated to everyone concerned.

Speaker’s Firsthand Experience

MotivationThere are two ways to do this. One is to bring someone who has been through an injury due to negligence. A lot of employees will gladly listen to a firsthand story on how accidents can be minimized if only safety precautions are followed. Not only will it be inspirational, it will also be a source of realization for employees who disregard the possibility of mishaps in the workplace.

Before ending safety talks, make sure that the audience knows the essence of such discussions – and that is to always be safe.

Women and Their Golf Shoes

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Golf shoes are not a requirement to play golf, even in the most exclusive golf clubs. The reasoning behind this is that most dress codes only require golfers to wear appropriate golf attire, which includes collared shirts, golf pants, or golf shorts. Therefore, the use, or non-use, of golf shoes is not strictly implemented since these are not included in the dress code for golfers.

GolfHowever, most professional golfers prefer to make use of golf shoes instead of any type of footwear when playing. This is because most professional golfers prefer to have a better traction on the course, in order to maximize their swing. This is aside from the fact that they appear to be a lot more fashionable compared to other players. Amateur golfers, therefore, follow this style trend by purchasing the appropriate footwear.

Traditional Footwear

Traditionally, these shoes are black and white wingtips that are made with leather and have tassels. However, these styles are considered to be too masculine by female amateur and professional golfers. They found those shoes to be rather unfashionable.

These women golfers do not have a choice since their numbers are significantly smaller compared to those of their male counterparts.The increase in the number of women golfers have resulted in the facilitated development of multiple shoe styles and colors. Women are considered to be the most significant market for shoe manufacturers. With regards to shoes, demand numbers often reach a minimum of around 5.76 million per year.

This is because women normally match their apparel with their shoes, as they also do when playing sports other than golf. Even with the modifications in the golf shoe, the main features remain the same, which are all about comfort, function, style, water resistance, and cost friendliness.

Comfort and Performance

The performance of the golfer depends on the comfort of the shoes, which means that it must perfectly fit the foot of the individual in various environments and weather. The shoe must be completely wrapped around the foot with little or no chaffing on the pressure points or shifts. This is because amateur and professional golfers require a lot of walking, especially when playing an entire course.

An entire 18 holes in a golf course will have different slopes and traps depending on what the designer had in mind. This means that the golfer may need to purchase golf shoes that have good traction as well as grip, such as those with spikes, nubs, cleats, or traction lugs. This is because the cleats or spikes will enhance the balance and stability of the golfer’s stance when doing a swing. Most golf clubs recently discourage their members from using shoes with metal spikes since those damage the grass on the golf course.

Brands and Styles

Golf ShoesThere are various offerings on the market that cater to every woman golfer’s preference, from sandals to boots, even to the traditional shoe. But golfers have to take into consideration that most of the golf courses are regularly sprinkled with water to retain the greenness of the course. This means that golfers who prefer to have their feet remain dry while playing will have to purchase shoes that are waterproof. The additional advantage of shoes with waterproof features is that they minimize the chance of slipping or losing traction while on the golf course.

As anyone would expect, it is crucial for a pair of shoes to be reasonable priced. The reasoning behind this is that women are perceived to be more fashionable and therefore, will purchase numerous shoes in different colors and styles to match their golf attires.

Rockbottomgolf is one of the best online store for purchasing golf shoes and other golf accessories. Here you can buy all golf brand products in one place.

The Importance of Arts and Crafts in Everyday Life

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artsWhen we hear the word “art”, what usually comes into our minds? Probably images of a museum filled with paintings, sculptures and other pieces of art masterpieces created by geniuses and masters. What about when we come into terms with “crafts”? Well, we may depict seeing children inside a classroom surrounded by colorful construction papers, glitters, glue, yarn and scissors in their hands, ready to create projects that become their own masterpieces.

We can also picture out various novelty items offered for sale at souvenir shops like pouches, bags, rugs, shirts and ponchos created through knitting, crocheting and macramé. In short, when the topic of arts and crafts is brought up, almost anything related to artistic ventures pops out of our thought bubbles.

Yes, we are absolutely right. Arts and crafts are all outlets of the creative artistry of man. Be it in the form of appreciable arts like music, literature, sculptures and paintings, or in handmade usable items like furniture, clothing and accessories, the imagination is at play with arts. Art is beautiful, functional and a means of expression. However, we limit our views to art depicted through the aforementioned media. We are not quite aware that art exists all around us, even in the simplest things we encounter in everyday life.

The world that we live in is wonderful. Life in itself is brilliant and worthy to be celebrated at all times, and art evident in the colorful human life, even in the earliest days. While many may not be aware of its existence or even its participation in everyday life, the main fact is that arts and crafts sit silently in a corner and reveal itself slowly to its beholders. Nonetheless, art is not just for making people look and admire at certain things.

craftsArt is seen even in the simplest and most useful object we may have in tow. Art exists in artificial and natural things. We gaze around and find a lot of beauty everywhere: a picturesque view of the mountains over a blue sky backdrop, a colorful bird serenading the trees, a picture on the office desk, tattoos of varied designs on the skin of elderly tribal members, dainty pink hearts printed on a baby girl’s swaddle blanket, the solid-colored but elegantly structured coffee mug at home – the possibilities of art are endless. You can see the many forms of art practically everywhere, even in places where it most likely cannot exist.

Since art encompasses almost every aspect of our lives, it plays a huge impact on life itself. Art is quintessential and will never fade, and it’s because it is important for all of us. Just when we thought only those people gifted with lovely creative hands and minds are entitled to enjoy as well as appreciate art and crafts, well, think again.

Each one of us has a special connection to art, and without it, our life will never be complete. The everyday grind of life brings us more opportunities to experience art and be a part of it, even if we aren’t aware of its importance in everyday life.

Art stems from within

Each person is gifted with the potential to imagine, express and create art. It does not matter if he things he is not the creative type, or he is not blessed with such talent. Everyone is capable of creating and expressing themselves through art. Look at small daycare children. Give them a box of crayons and a sheet of paper and without hesitation, each one will come up with colors, patterns and pictures that they wish to portray.

Getting inside the hearts and minds of people with impaired mental abilities is also achieved simply by looking at the artworks they create. When expressing ourselves, art is the best medium to turn to, because people read between the unspoken and the known through art; hence, it becomes a form of communication when all possible means fail because it comes from the depths of our souls.

Art stimulates our mind

In creating or viewing arts and crafts, the human mind works as much as when it tackles other kinds of activities. It also improves critical thinking. How? When we decide to create something, we conceptualize what we want to achieve, then work meticulously to get the end result we have in mind. In the event that we view other people’s work, we use logic and critical thinking to interpret these artworks and decode what the creator wishes to say through the artwork, thus, it stimulates and improves cognitive function and helps the mind develop skills that will be helpful to everyday life.

Art is a form of self-awareness

It is difficult to show the world the true emotions we feel deep within. When facing such a challenge, arts and crafts can come to the rescue! It is the perfect channel to present our thoughts and emotions. By creating different forms of art, we come into terms with the actual emotions we truly feel, thus, we become more self-aware. In addition, it allows us to slow down from the fast-paced everyday grind and experience what our emotions really want to say to us.

By looking at other people’s artworks, we stir up our own emotions, broaden our understanding, and explore the world more clearly in other’s eyes and hearts as well. Art enables us to have ample space to grow and improve ourselves emotionally through increased self-awareness.

Art helps us transcend to other society’s cultures

One unique attribute of arts and crafts is that people across cultural differences can understand it. Art is a universal form of communication; hence, people from different sides of the planet can bridge the gaps of distance, language and culture and still understand each other. Through art, we see a glimpse of the culture and life of a certain society and learn more about their life and ways. Art is a powerful tool to cross international borders and discover new ways of life that are unique from our own.

Art makes life more radiant

Life in itself is wonderful, but arts and crafts makes it even more radiantly beautiful. Imagine living and working in places where there is only all functionality and no beauty. It will be boring, for sure. Throw in some art and we’ll see the place liven up! Art makes our lives more interesting and creates more worth in living it. It is great to be surrounded by different expressions of human beings, tangible through artworks and crafts, and it’s equally great to have the ability to express what is in the depths of your being. Art shines as the best medium to utilize for self-expression. In using art, we all celebrate life and make the world a beautiful and colorful place to live in.


Our focus is primarily bottom-up research on a limited number of companies, but we also try to improve our long term results by investing counter-cyclically - increasing our total market exposure in times of crisis and reducing our risk gradually as the market recovers.


Athletes, Ego, and the Post-Competition Blues

Sport Psych Webinar

Note: There is a very distinct difference between an athlete that may be feeling down and out after a victory, and an athlete that is suffering from clinical depression. It is imperative to emphasize that if you are coaching an athlete who you feel may be clinically depressed and/or is having suicidal ideations, these are symptoms that require intervention from a licensed clinical Psychologist. Mental Skills Training and effective coaching can go a long way to enhance mood and confidence, but do not hesitate to refer your athlete to mental health professionals if you see signs of a deeper pathology.

It is not unusual for athletes, particularly athletes in individual sports, to feel down or depressed during the post-competition period*.

When suffering a defeat this is understandable, but this also occurs in athletes who are victorious and meet or exceed their goals, especially as a general feeling of ‘what’s next?’ creeps in. The anticlimactic nature of winning, for some, can be a great source of anxiety and erode motivation, often leading to discontinuing sport or causing the athlete to delay further competition for extended periods time.

For many, this seems quite counter-intuitive. Why would one feel down or depressed after winning a race, setting a PR, or taking the overall at a Bodybuilding Show? Performance Psychology tells us that the answer to this paradox lies in the Goal Orientation of the athlete.

As many of you know, much of my Sport Psych approach concerns itself with Goal Orientations, specifically Ego vs. Task Orientation, which will be briefly discussed below.

The Ego Orientation

In an Ego Orientation, we find athletes primarily concerned with their abilities and performance in the context of their peers. Ego Oriented athletes value winning above all, and competition is used as a platform with which to showcase their superiority, as well as to gather data about their weaknesses when compared to other athletes in their class/event/age group. Ego Orientation can be an effective means of motivation, but it has drawbacks. For one, ego oriented athletes tend to lean heavily on performance or outcome goals (i.e. “Winning the Overall Bodybuilding title at Nationals”, or “Run the fastest American 5k time in 2017”). Performance and outcome goals have a very important role in the goal setting process, but they are also goals that offer the athlete very little control. What if an opponent has the race of their life? What about environmental conditions? Unexpected acute illness

In these cases, it is easy for an ego oriented athlete to overlook the progress they have made throughout their process of training and improvement and simply focus on a poor outcome that was not within their control. These athletes miss the forest despite the trees, and with no documentation of progress and no goals that actively stress process (form, technique, consistency), this leads to an overall lack of documented successes throughout the training cycle. Indeed, these athletes often only have the competition itself to use as a litmus test for success. To lose an event is to fail at the entire process. Worse yet, in an environment where only winning matters, ego oriented athletes run the risk of developing deleterious coping mechanisms in order to “save-face” in the event of loss, such as self-handicapping.

In the context of a post-competition slump, the Ego Oriented athlete has reached their long term goal and is stuck with the proposition of figuring out a direction to take. With these athletes, oftentimes their long-term vision is simply to narrow and adjustments are not made as milestones and short-term goals are surpassed. Essentially, their attention on the goal of the competition was so laser focused that they failed to understand that there is life beyond a win. Instead of thinking ahead, even momentarily, as they approached the competition, they stayed completely locked in.

Now, to label Ego Orientation “bad” is a short-sighted assessment. Particularly with regards to elite/professional athletes, it is all but impossible to find individuals in this population that do not have some sort of burning desire to defeat their opponents and be the best at their sport in an objective way. Tell an Olympic sprinter that they are too focused on winning a medal, and things won’t go so well for you as a coach. You could also try walking into the front office of an NFL team and letting them know that they need to de-emphasize winning. Please let me know if it works out.

The fact is, with most elite, professional, or simply just competitive athletes, you are not going to eradicate an ego orientation. In fact, some of the premier researchers in the field, advise to simply let it be and focus on bolstering a Task Orientation. In the end, the amount of time needed to rewire someone to forgo their ego orientation (which isn’t likely possible) isn’t worth it and time would be better spend placing the entire focus on developing a task oriented mindset.

The Task Orientation

The Task Oriented athlete is focused on the process. Competition is still important, but rather than using competition to compare themselves with other athletes, a task oriented athlete will compare current performances and outcomes with past performances and outcomes as a metric to assess their current training. As such, task oriented people set up and track numerous process goals as milestones toward their ultimate long-term goals.

Because of this, the locus of control is shifted externally, to the athlete. Focusing on tasks and creates an environment of success where small wins can stack up and snowball into increased self-efficacy and motivation. To this end, a bias toward tasks places the athlete in a mastery mindset: winning is nice, but the true goal is improvement and the ceaseless march toward mastery, while using previous performances. The endgame here is to be the best one can possibly be and put forth the greatest possible effort with every training session and competition, with attention placed on the ability of competitors being mere periphery.

As well, there are other advantages to this orientation. For example, Task Oriented athletes tend to cope better, display higher overall satisfaction with their sport

Practical Application for Post-Competition Blues

With a basic understanding of the above concepts, it is clear what is going on with a successful athlete that is feeling down after a successful competition, and one major component of this is their orientation.

As stated earlier, most high performing athletes are going to be Ego Oriented to a degree, so it is best to focus coaching efforts on making the overall climate more task oriented. The following tips can help in creating an environment that facilitates a task/mastery orientation. Remember, if you are working with accomplished athletes, removing ego orientation is going to be impractical, if not impossible:

1. Ensure your coaching is focused on the development and improvement of skills, rather than a win/loss record. Create an atmosphere that define success in terms of effort and progress.

Mastery trumps ego. As a coach, look to stress effort and improvement over the win loss record. As such, emphasis should be placed on the competitors that athletes are facing and their skills, but rather on your athlete’s progress and skillsets that are applicable to sport. Indeed, knowing one’s opponents is critical, but place that in the proper priority.

2. Teach athletes to embrace the process and track improvements.

Compliance can often be tricky when it comes to having athletes maintain a training log that tracks multiple variables. The key if to work with the athlete to develop a tracking tool that works with their lifestyle and contains the metrics that matter to them most, while simultaneously de-emphasizing the ego oriented metrics.

3. Assess and evaluate athletes based on development and progress, not wins or losses.

Wins and losses are often out of the control of the athlete, so focus on evaluating athletes objectively, using progress and skill development metrics as the standard. Athletes that played under legendary coach John Wooden have often remarked that he never really spoke about winning or losing, but rather focused on improvement in the fundamentals. Given his track record, it is a good idea to emulate him.

4. Provide objective feedback on athlete performance based on effort and status of skill development. Avoid unnecessary subjective feedback, both positive and negative.

Speaking of Coach Wooden: he was once observed by researchers who noted that 85% of the statements that came out of his mouth were instructive in nature. 85%! Nothing judgemental or subjective about their performance, but rather objective instructional feedback: “That was correct, do it the same next time” or “That pass was mistimed, note the position of the defender next time and adjust”. No unnecessary praise or criticism, just objective feedback as needs dictate.

4. Place heightened emphasis on process goals.

In most cases, athletes are already overemphasizing the competition and its outcome. Provide other reasons to justify dedication, hard work, and dedication. When you are working with your athletes in goal setting sessions, express the importance of process and progress goals, as well as the importance of having a grand vision that can stretch out for years down the road. Athletes should not be competing from event to event, but rather aiming for a long-term goal of sport mastery.

With the way most Western societies view competition, there will always be a bias toward ego orientation. As coaches, the onus is on us to ensure that we are creating environments that are facilitative to mastery and growth. By stressing effort and progress, and aligning goals to match a long-term vision, we can prevent athletes from feeling depressed and lost, both after defeats and victories. Remember, competition and outcome goals, while critical, do not provide athletes with enough control to ensure 100% success. Focus on mastery and the wins will follow.

* Although athletes in team sports are not immune to this, I speculate that the concept of relatedness (i.e. belonging to a team with a shared struggle) provides team athletes with insulation from this.