By Michelle Soares Mendes
Most people will experience tinnitus if the situation is quiet enough. A study was conducted where medical students were placed into a soundproof booth and within 5 minutes 95% of the subjects began to hear tinnitus. 18-20% of the population report experiencing regular tinnitus, many are not bothered by it, but some are. Why is this?
Most people will spontaneously habituate or adapt to their tinnitus over time, so that while it may be heard, attention is rarely given to it and emotional acceptance of it is achieved. Our brain’s default process is to habituate to familiar stimuli so that we are not overloaded with unimportant information. If we constantly got reminders from our brain at a conscious level that we could feel the sensation of clothes on our body we’d have little time to process everything else that was going on too. Habituation is what is supposed to happen. But sometimes it doesn’t. Why?
The most common reason that we begin to hear our tinnitus more frequently is as a result of hearing loss. Tinnitus is more audible in quiet and just like the student in the sound booth, a hearing loss deprives us of sound stimulation. In a quiet world we will hear the internal noises more often and the more often we hear them the more likely they are going to enter into our conscious processing.
So then comes the next 2 reasons that we don’t habituate to our tinnitus, sustained activation of the limbic system and of the autonomic nervous system. Negative associations may develop in response to the tinnitus signal. These may be subconscious (such as fear of the new unknown threat) or conscious (beliefs about the tinnitus). More time is devoted to monitoring tinnitus. The autonomic nervous system may trigger physiological responses (such as the flight and fight response) including sweaty palms, increased heart rate. A conditioned response develops and feedback loop intensifies. The tinnitus becomes more frequently noticed, it’s perception is intensified and the responses from the limbic and ANS are reinforced.
So the goal of Tinnitus Therapy is to facilitate habituation of tinnitus induced reactions and tinnitus perception, resulting in decreased awareness of it. How is this achieved?
With a background in both audiology and psychology I have found great success in utilising (and referring for) a combination of Tinnitus Retraining Therapy (P Jastreboff) based on the Neurophysiological Model of Tinnitus and Neuromonics Treatment. These incorporate the use of directive counselling, sound therapy, amplification, relaxation & sleep management. Where required I also refer for management of anxiety, depression, PTSD (sudden noise induced tinnitus in association with hyperacusis), TMJ specialist, pain management (tinnitus in association with acoustic shock disorder, Tonic Tensor Tympani syndrome).
An initial tinnitus appointment will consist of a comprehensive case history and tinnitus rating questionnaire (Tinnitus Reaction Questionnaire) as well as an audiological assessment for which organic triggers of tinnitus are assessed. I may refer back to yourself for further investigation. On many occasions noise induced hearing loss or presbycusis are identified and tinnitus is pitch matched to the frequency of poorest hearing – this is no coincidence!
Directive counselling is tailored to the individual’s unique set of circumstances but always begins with an explanation of the Neurophysiological Model of Tinnitus (Jastreboff) and a postulate of where I believe the individual sits within this feedback loop. Counselling involved demystifying tinnitus, challenging maladaptive beliefs about tinnitus and subsequently neutralising the patient’s negative emotional associations. Tinnitus habituation cannot occur for stimuli that have strong negative associations. Strategies for managing stress and sleep are discussed. Where there is abnormally high activation of the limbic and autonomic nervous systems, anxiety or depression may result. Where required, onward referral is initiated.
However counselling alone is not effective in treating tinnitus. If tinnitus is present on a regular or constant basis the feedback loop to the central nervous system continues to be strengthened. So in combination with counselling, sound therapy is used. Sound therapy is designed to reduce the perceived loudness of the tinnitus above the external background sounds. Less frequent perception of tinnitus and at a lower perceived volume enables the individual to gradually desensitise the persistent tinnitus. Sounds administered for sound therapy may range from white noise, gentle meditation music, environmental sounds, an overhead fan, noise generators or hearing aids. Sounds may be delivered via phone aps, custom ear pieces, bedside sound therapy system, CD player or pillow speakers.
Hearing aids are considered a beneficial form of sound enrichment if hearing loss is present. These will enable the patient to use less listening effort in communication. Less listening effort means there is less internal gain of sounds that are not supposed to be amplified (such as tinnitus). Most hearing aids available also have the option of an internal sound generator program for use in quiet times where amplification is not required, but the environment is otherwise too quiet for tinnitus retraining to be possible. Very quiet situations are to be avoided. Hearing aids may also have the option of Bluetooth transmission to connect to phones with music apps such as Spotify, another option for sound therapy.
I do not ‘mask’ tinnitus. This is to be avoided. If the patient cannot hear the tinnitus above the sound therapy device, then there is no available stimulus to which to desensitise from. In fact blocking out the tinnitus altogether temporarily only leads to a worsening of tinnitus when the device is removed. The brain needs to hear some degree of tinnitus so that it can associate the signal with a neutral meaning, ‘there is that sound that no longer bothers me, I hear it just like I hear the fridge, it doesn’t mean anything significant to me’.
Most often a tinnitus program will consist of just one consultation. These run for 90 minutes preceded by the completion of a detailed questionnaire and resulting in recommendations and strategies provided to the patient and a subsequent report. Where additional appointments are required a costing will be quoted for any devices and a recommendation made for a Chronic care plan to assist funding options.
Outcomes for tinnitus management are generally very effective and quick. Reduction of the intrusiveness of tinnitus is achieved generally within a few weeks in cases where non-custom devices are recommended for sound therapy. When there is a need for custom sound therapy devices, relief tends to also be within a few weeks whilst the devices are worn. When not used (such as in the evening) the tinnitus returns to its’ previous level. From 3 months onwards relief from tinnitus is also found both with and without the application of the custom sound therapy devices.
Dineen, R., Doyle, J., Bench, J. & Perry A. (1999). The influence of training on tinnitus perception: an evaluation 12 months after tinnitus management training. British Journal of Audiology, 33, 29-51.
Jastreboff, PJ, Hazell (1997) Treatments of Tinnitus, Allyn & Bacon
Jastreboff PJ, Gray WC Gold SL Neurophysiological approach to Tinnitus patients, American Journal of Otology, 17:236-240, 1996
Jastreboff PJ. Phantom auditory perception (tinnitus): Mechanisms of generation and perception. Neurosci Res. 1990;8:221–54