Tinnitus Distress

Tinnitus, the experience of sound without an external source, affects 10-14% of the population. Most people with tinnitus (~75%) do not find it very bothersome. However, tinnitus can cause distress and impairment when our brain misinterprets it as threatening.

Numerous studies have found that how we intrepret and respond to tinnitus–not the properties of tinnitus itself (loudness, pitch)–best explains whether or not we experience tinnitus distress.

However, tinnitus seems louder if we are (understandably!) distressed by it. When a sound or other sensation is linked to threat, our brain boosts its signal, making it easier to detect and harder to ignore. Worse, once our brain thinks a sound is important, it will prevent us from habituating to it.

Habituation

Usually, our brains are highly proficient at tuning out unimportant sounds. Right now if you scan your surroundings, you can probably find a sound that your brain tuned out and bring it back into awareness. Our brains actually form memories of which sounds are unimportant, so we can automatically ignore them on subsequent encounters. However, if a sound gets on the registry of our brain’s alarm system, habituation is blocked until we teach our brain that the sound isn’t important–that it’s okay to tune it out.

The psychologist Dr. Richard Hallam recognized that the brain’s alarm system blocks habituation of tinnitus in the 1980s, and his insight informed the popular “neurophysiological model” of tinnitus distress by otolaryngologist Dr. Pawel Jastreboff. However, Dr. Jastreboff underestimated the challenge of teaching the brain that a phantom sound causing distress and impairment is not actually important. The brief counseling in his tinnitus retraining program (followed by sound therapy believed to facilitate habituation) is usually not sufficient to render tinnitus neutral and unimportant.

Cognitive Behavioral Therapy for Tinnitus Distress

Fortunately, psychologists have developed highly effective treatments for anxiety disorders, and these treatments apply seamlessly to tinnitus distress. Indeed, there are several anecdotes of psychologists developing severe tinnitus distress and slowly realizing they could treat themselves with CBT or Acceptance and Commitment (ACT) therapy, approaching it as an anxiety-related disorder.

Both CBT and ACT have proven effective in reducing tinnitus distress and improving quality of life. These treatments work by teaching the brain that the tinnitus sound isn’t harmful–that it’s not important–allowing the process of habituation to begin and to proceed through the four stages recognized by psychologists.

The key element in overcoming tinnitus distress, just as in overcoming an anxiety disorder, is changing our behavior to allow corrective learning in the brain. ACT provides a particularly useful framework for tinnitus. As Dr. Bruce Hubbard explains, acceptance involves letting “tinnitus do what it wants to do." We let go of efforts to control tinnitus, and we resume activities that we were avoiding because they make tinnitus more noticeable, or because we fear they will make tinnitus worse. This exposure is a gradual process, and sound enrichment is used to make it easier at the beginning.

Finally, mindfulness skills are particularly helpful with tinnitus. Mindfulness involves cultivating non-judgmental awareness of the present moment and letting go of distractions. Practicing mindful awareness of tinnitus is one of the primary means of accepting tinnitus and teaching our brain’s alarm system that it’s not harmful or important. Mindfulness practice also helps us return our attention from the tinnitus sound (or worries and ruminations about tinnitus) to more important details of the present moment.

This page from the American Tinnitus Association offers guidelines on when and from whom to seek treatment following the onset of tinnitus. I see clients with tinnitus after they have visited a primary care provider (to diagnose/rule out certain causes) and an audiologist (to provide further insight into potential causes and to provide specialized evaluation, including hearing tests). The vast majority of cases of tinnitus are “primary” rather than “secondary,” meaning there is no underlying cause besides possible sensorineural hearing loss (noise-induced or age-related).

How people rate the severity of their tinnitus (Bhatt et al., 2016)

One risk factor for tinnitus distress: Valuing silence

If you find tinnitus bothersome, it does NOT mean that you are weak or did something wrong. Our emotional response to tinnitus is determined by many different biological, psychological, and social factors. A family member of mine who developed severe tinnitus distress was at greater risk because she valued silence. Also, earlier in her life, she encountered a sensational story about tinnitus distress, and concluded that if she ever developed tinnitus, she would find it particularly bothersome (her actual language was more colorful). Thus, she was primed to have a strong emotional reaction to tinnitus (and she did). Each encounter with a provider made it worse by reinforcing her assumption that she would never be happy and at peace again, because there was no cure for tinnitus.

Undoing Tinnitus Distress

Fortunately learning about the nature of tinnitus distress (“psychoeducation”) and the hope for habituation helped my family member rethink her interpretation of tinnitus. Accepting that tinnitus was out of her control, she began pursuing values other than silence, and her quality of life improved quickly. Now she can notice tinnitus when she looks for it (and the sound hasn’t gotten quieter), but like the hum of a refrigerator, it’s usually outside of her awareness, unless it comes on when she’s not paying attention to anything. And like the fridge sound, her brain can now easily tune it out once she shifts her attention elsewhere.