Patient Care: Tinnitus | August 2007 Hearing Review

A look at reactions and solutions to tinnitus within a CBT framework

By Laurence McKenna, PhD, and Gerhard Andersson, PhD

Editor’s Note:This article was adapted from a chapter of the upcoming book The Consumer Handbook on Tinnitus, edited by Richard Tyler, PhD, of the University of Iowa. Written for consumers, but also intended as a resource tool for clinicians, the book will be available in spring 2008 from Auricle Ink Publishers, Sedona, Ariz (www.hearingproblems.com). HR thanks Dr Tyler, the authors, and Auricle Ink Publisher Richard Carmen, AuD, for the use of this excerpt.

The first really important thing to know about tinnitus is just how many people have it. About 10% of the adult population has tinnitus—a huge number of people.

The next thing to know is that there is a big variation in how people react to tinnitus. Most people with tinnitus get along without being distressed by it. Other people suffering from tinnitus may experience feelings of anxiety or depression. They can become withdrawn or restless. They frequently complain of poor sleep, difficulty in everyday functioning, or a reduced quality of life. Some people feel the need for antidepressants, sleeping pills, or other tranquilizers.

Laurence McKenna, PhD, is a clinical psychologist with the Royal National Throat Nose and Ear Hospital in London where he heads the Adult Audiological Medicine unit. Gerhard Andersson, PhD, is a professor of clinical psychology at Linköping University (Sweden) in the Department of Behavioural Sciences and Learning and is a guest professor at the Karolinska Institute, Stockholm, Department of Clinical Neuroscience, Psychiatry Section.

For example, one of our patients, a well-educated, high-earning financier we’ll call Bill, became very anxious when he developed tinnitus. He took sick leave from work and withdrew from his family and friends. Bill spent periods of time in bed or lying on his sofa. His doctor prescribed him tranquilizers and antidepressants. This may sound like a sensible treatment course, but most people with tinnitus are fine emotionally. It is also the case that you can have a lot of problems with your tinnitus for a limited period of time, and then move on to a calmer period during which you are much less annoyed by it. Obviously, most people would rather not have tinnitus; however, after an initial stress reaction to it, most carry on leading normal, healthy, fulfilling lives. The majority do not attend tinnitus clinics or require medication.

Many people who come to our clinics suppose that suffering is an inevitable consequence of having tinnitus. How often have we, as clinicians, heard a patient say, “Of course I feel like this. I have tinnitus!” Some people see an inevitable link between having tinnitus and feeling bad, but this link is not inevitable. It is possible to have tinnitus and still be okay.

Remember, most people with tinnitus are okay. After an initial stress reaction, they simply stop reacting to the same boring tinnitus sound and become largely unaware of their tinnitus for most of the time. This process is called habituation, and it occurs naturally as long as the person regards the tinnitus as meaningless. Many people are greatly relieved to hear this. However, some of our patients, like Bill, protest by saying, “Sure, other people might be okay, but they can’t have bad tinnitus. Mine is really bad, and anyone who has what I have in my ears/head is bound to suffer. Surely, no one could habituate to a noise like this.”

The link, however, is not so inevitable. People with all kinds of tinnitus can be fine and people with all kinds of tinnitus can suffer. Do not despair if you have tinnitus; the outlook is very good. You too can get to a point where tinnitus does not play a prominent role in your life. Many of our patients find this hard to believe at first, but it is true.

Why the Reaction to Tinnitus?

The evidence is that psychological processes, and not just audiological physiological ones, make a real difference in whether or not habituation takes place. Distress due to tinnitus involves a lot of worry or overly negative thinking, a change in the way the person does things, a high level of stress anxiety or tension in the person’s system, and a decline in mood. Let’s look at each of these in turn.

Thinking About Tinnitus

This is the most important bit; once this part is understood, everything else falls into place: Psychologists believe that how you think about things determines how you feel. In other words, how you think about what is happening to you can be more important than what is actually happening.

Different people might think about the same thing in different ways and therefore feel very differently about it. For example, a person who believes that his or her tinnitus is a symptom of a brain tumor will feel anxious as a consequence of that thought. When his tinnitus first began, Bill thought it was the result of poisoning from a radioactive dye he received when he had an MRI scan. It is easy to understand that, with the words “poison” and “radioactive” spinning around his mind, he felt highly anxious. Fortunately, it was quite straightforward to reassure him otherwise.

However, the reassurance process is not done only by convincing a person that he or she is mistaken. On the contrary, a cognitive perspective calls for a collaborative stance where the evidence is reviewed, and all worries and concerns are taken for real until they have been carefully scrutinized and discarded. Those who think tinnitus is of no significance to their health or well-being are likely to feel much calmer.

The danger instinct and overgeneralizing. People think about things in different ways at different times. For example, we’ve all had the experience of worrying about a problem in the middle of the night. The problem can seem huge and insurmountable, and we feel terrible. By lunchtime the next day, the problem may not have gone away, but it seems more manageable and we feel better about it. We can therefore think differently about the same problem at different times, and it is the thinking that leads us to feeling either stressed or calm.

We also know that, when people are stressed, they view things in an overly negative way (we will refer to this as “middle-of-the-night” thinking, even though it may occur day or night). This is not to say that people are foolish to see problems where none exist; rather, they are more likely to view things as dangerous. Recognizing danger is an instinct that helps us stay alive. The problem comes about when middle-of-the-night thinking predominates, causing us to become overly negative.

Although Bill was easily reassured about not having been poisoned, he developed several new ideas about his tinnitus. He went to a wedding reception and was seated next to a loud band. He thought that the noise would make his tinnitus worse and he quickly left. Sure enough, his tinnitus was more intrusive after he left, but it returned to normal later. He then assumed that all everyday loud sounds would make his tinnitus worse and that his tinnitus would continue to grow until he became a bed-bound invalid. He told himself that he could no longer enjoy life. When he saw retired people, he envisioned himself as an older person unable to function because of tinnitus. When he had this image, he was overcome by feelings of anxiety and sadness.

It should be recognized that most people will experience some tinnitus when exposed to very loud sounds, such as those produced by the band at the wedding. As long as the exposure is not too long or loud, then the tinnitus will usually disappear. Bill took his (normal) experiences with the band and generalized the idea to a very wide range of everyday settings. In a nutshell, he overgeneralized the problem.

This is something that can happen to anyone under stress. Our thoughts can become distorted in a number of ways, causing us to see one or a few negative events as a never-ending pattern, or thinking about things in all-or-nothing terms. Once our thoughts take on this middle-of-the-night distortion, a vicious cycle of negative thoughts and moods is set in motion. When tinnitus is involved in this cycle, a person can have a very bad time.

Some people will say that they don’t know what they think about tinnitus and that they try to not think about it. It is important to recognize that, if you are feeling bad about your tinnitus, it is because you do have ideas about it and those ideas are worrying you. Research tells us that people who suffer from tinnitus think about it much more than people who have tinnitus but do not complain about it.1

Key facts. Many people have tinnitus, but not everyone suffers from it. The evidence indicates that, when a person does suffer, it has less to do with the psycho-physical aspects of the tinnitus and more to do with the worry about tinnitus. When a person drops into overly negative or middle-of-the-night thinking about tinnitus, he or she will suffer.

Suffering from Tinnitus

Decline in mood. Worrying about tinnitus triggers a number of processes. The most obvious is a decline in the person’s mood. For many people, this takes the form of feeling anxious or nervous. Bill’s original belief that he had been poisoned led him to feel anxious and angry. Later, his belief that everyday loud sounds would damage his hearing and worsen his tinnitus led him to feel more anxious.

Anyone who really believes this idea would feel anxious. Holding other beliefs will lead to other types of moods. People with tinnitus often complain of feeling depressed, sad, irritated, anxious, frightened, panicky, agitated, angry, ashamed, or some other unpleasant mood.

What mood you feel depends on what you are saying to yourself about your tinnitus. Once a negative mood takes hold, it has a reinforcing effect on negative thinking. When we feel depressed we are more likely to have depressive thoughts; when we feel anxious we are more likely to have anxious thoughts, and so on. How we think about things, including tinnitus, really depends on “what side of the bed we got out of.”

High level of anxiety. Negative thoughts not only lead us to feel anxious, angry, or depressed, they also lead to a change in the level of stress arousal, or anxiety, in our bodies. The physical changes from anxiety are an integral part of the emotional experience. When we are in an anxious/aroused mood, we also have changes in our bodies, such as increases in heart rate, muscle tension (including a feeling of tension and sometimes pain in the head, neck, and shoulders), breathing rate, and digestion rate. In the upper gut, things actually slow down, and we feel butterflies or nausea, as well as an increase in frequency and urgency to use the toilet. Many tinnitus patients complain of such symptoms, particularly headache or pains around the ear and a general feeling of being tense. There are many other physical changes that can take place, such as sleeping difficulties.

These changes can be frightening if you don’t know what is going on and mistake the symptoms for illness, or worry that they will have some other damaging effect. Bill experienced a sensation like a tight band around his head. He felt incredibly tense, and suffered with nausea and diarrhea. In this way, there can be a vicious circle of negative thoughts and physical symptoms of anxiety.

Increased anxiety also has other less physically obvious effects. In particular, increased anxiety causes a person’s attention to focus ever more narrowly on the thing perceived as a threat. As a result, people who believe that tinnitus is a threat to their well-being focus their attention on tinnitus to the exclusion of other things. This is known as selective attention, and its effect is very deleterious in this situation. Just imagine what would happen if you lay on your bed for 15 minutes and did nothing but focus your attention on your tinnitus. It would surely seem much louder and more intrusive.

We believe that it is this process that leads people to describe their tinnitus in terms such as “like a jet engine” or “like a jackhammer.” It also leads people to hear their tinnitus even when other loud noises are present.

Changes in behavior. Most people who perceive themselves to be in danger will try to avoid more danger. This is usually helpful, but when the perceived threat results from thinking about things in a middle-of-the-night way, then actions that keep you safe are likely to be unhelpful. Remember, middle-of-the-night thinking leads to seeing problems as bigger than they are. In such circumstances, actions that keep you safe are likely to mean that you will not find out that you have overestimated the extent of the problem (ie, that you are caught up in an anxious or depressed thinking trap). The overly negative thoughts are perpetuated.

For example, Bill’s belief that everyday loud sounds would damage his auditory system and worsen his tinnitus led him to keep away from such noises. He avoided noise as much as possible, even to the point that he insisted that his family be as quiet as possible. His children had to play quietly in another room, and his wife would wait until he left to use the vacuum cleaner. This safety behavior meant he did not find out that everyday loud sounds would not damage his auditory system. These thoughts went on provoking his anxious mood, his stress anxiety, and his focus on tinnitus.

Bill kept his environment quiet, but it is also common for people suffering with tinnitus to do the opposite and avoid quiet situations at all costs. This can be equally unhelpful if it prevents finding something out or testing an idea (eg, “My tinnitus would be unbearable without background sound”). It’s also likely that the continual “noise load” contributes to the person’s anxiety.

What Needs to Happen to Change These Reactions?

If you are distressed by tinnitus, probably the largest key to reducing that distress is changing how you think about tinnitus. There are no rules that dictate how this can be achieved, but there are some tried and trusted methods.

The first thing to do is to understand what is going through your mind regarding tinnitus. This might be done through discussion with a psychologist or tinnitus therapist. It can also be done by noting what goes through your mind when you are feeling distressed by your tinnitus. There are some ideas about identifying worrying thoughts in the section below, “How Can I Help Myself?”

You are almost certainly just accepting the thing(s) you are saying to yourself about tinnitus as accurate. Although these ideas will seem very compelling, you must remember that they are ideas rather than facts. Also remember that, if you are feeling distressed, these ideas may be the result of middle-of-the-night thinking. They need to be tested rather than just accepted.

You may be able to test how accurate they are by discussing them with your therapist. Bill was able to change his ideas about his tinnitus resulting from radioactive dye poisoning through discussion with one of us, and he felt better for it. Many ideas can be tested in discussion (eg, “It is unfair that I have tinnitus” or “My tinnitus will lead me to go mad”). The strength of some other ideas, such as Bill’s idea that “noise will make my tinnitus worse,” can be weakened by discussion. However, the situation will probably not change substantially unless behavior is changed, such as deliberately spending time in a noisy environment. Bill did this and his tinnitus did get more intrusive; he realized that his tinnitus worsened because he was anxious and checking it. It returned to normal after awhile.

When ideas and behaviors change, moods and levels of anxiety will decline correspondingly. You may want to help reduce anxiety by learning some proper relaxation exercises. All of this helps tinnitus become less intrusive and just an innocuous part of the background.

How Can I Help Myself?

Identifying your worries and concerns about tinnitus. The starting point is to find out what your ideas about tinnitus are. Ask yourself: “What is going through my mind about tinnitus?” The best time to ask this is when your tinnitus is intrusive and you are feeling distressed. It is at that time that the thoughts will be easier to “catch.” Write down your thoughts. Keep a pencil and paper handy. At this stage try not to write down a reasoned argument about what is happening; just try to catch the “unhelpful thought.”

Becoming aware of the content of your thoughts can be a difficult thing, and many people find that it takes practice. Typical worrying thoughts that people have about tinnitus are:

  • I will have a nervous breakdown
  • This will ruin my physical health
  • I will never get any peace and quiet
  • I can’t enjoy things now
  • I can’t do normal things anymore
  • I must avoid loud sounds/silence

These are just a few examples of people’s thoughts about tinnitus. It is important to understand your own ideas about tinnitus; don’t try to produce a carefully reasoned piece of prose about your tinnitus. Rather, try to discover the actual words or images that go through your mind.

Generally, the thoughts of people who are truly suffering with tinnitus reflect despair, persecution, hopelessness, loss of enjoyment, a desire for peace and quiet, and a belief that others do not understand.2 Other common themes are resentment about persistent tinnitus, a wish to escape it, and worries about health and sanity.

Another way of identifying thoughts about tinnitus is to ask yourself what you are doing, or not doing, because of your tinnitus, and then ask why you are acting like this. It is often necessary to ask yourself what the implication of your idea is. For example, if the first idea that you write down is “My tinnitus will never go away,” then it is useful to ask “What does this mean for me?” If the answer is something like “It means I will never be able to enjoy things anymore,” then this idea is the one that you will need to work on.

Researchers have shown that tinnitus clearly reduces the quality of life of older adults. For details, see the April 26, 2007 edition of HR’s THe Insider e-newsletter in the Insider Archives.

It is sometimes necessary to keep asking what the implication is of each refinement of the idea in order to get to the heart of the matter. This approach to questioning ideas is called laddering because you are taking the idea to a new rung each time. Ideas often combine to create a mix of feelings. For example, people who believe that having tinnitus means that they have lost the ability to have peace and quiet are likely to feel sad, but they may also feel anxious if they then believe that a lack of peace and quiet will lead them to go mad.

Once the ideas have been identified, it is helpful to make the link between ideas and mood. Understanding that ideas trigger moods can help you change things. Just saying “I feel down and I don’t know why” is unlikely to help you change anything.

Taking control of middle-of-the-night thinking. It is also helpful to remember that how you feel can also influence your thoughts. Feeling bad can lead to middle-of-the-night thinking. Consider whether your ideas fit into one of the typical patterns of middle-of-the-night thinking:

  • Overgeneralizing
  • All-or-nothing thinking
  • Ignoring positive information
  • Minimizing positive information and magnifying negative information
  • Using a mental filter wherein a small piece of information is dwelt upon that colors your vision of reality
  • Emotional reasoning causing you to believe that, because you feel something is true, it must be true
  • Jumping to conclusions by making negative interpretations without firm evidence to support the conclusions

When you realize that one of your ideas fits a well recognized pattern, it can make change easier. For example, overgeneralizations and all-or-nothing thinking were characteristics of Bill’s thinking. When Bill began to understand that his thinking was skewed in these ways, it encouraged him to look for alternative ways of thinking about tinnitus.

Seeking a Balanced Perspective

The approach to tinnitus described here involves cognitive behavior therapy (CBT). CBT is not simply about looking on the bright side, positive thinking, or pretending that bad things are not happening; it is about seeing if there is any other way of looking at what is happening to you, and taking on a more accurate or balanced perspective.

How Can a Psychologist Help?

Many people successfully change their reactions to tinnitus by going through the processes outlined here. It can, however, be difficult to understand your reactions and change them on your own. Professional help can make a real difference.

There are different schools of psychology and we recommend that you consult a psychologist trained in cognitive behavior therapy (CBT). At the time of writing, few cognitive behavior therapists specialize in treating people with tinnitus, but most should be able to apply their CBT skills to the problem and help a person with tinnitus. For help in finding a cognitive behavior therapist in your area, consult the British Association of Behavioural and Cognitive Psychotherapists (www.babcp.com) or the American Association for Behavioral and Cognitive Therapies (www.aabt.org).

A therapist trained in CBT will help you understand what is going through your mind relative to tinnitus. They will ask you about your tinnitus, and your reactions to it. They will listen carefully to how you talk about it and reflect back to you the things that you are saying. Having another person listening and discussing your problems can lead to a much more objective view of your situation.

On this basis, they will probably give you homework tasks. The homework will help you discover more about your thoughts and reactions to tinnitus. The therapist will also help you to discover whether your thoughts about tinnitus are accurate. They can be enormously helpful when it comes to planning how to do things differently so that your ideas can be tested.

Many people get tinnitus for the first time during or after a period of high stress. Alternatively, a person’s tinnitus may get much more intrusive during a period of stress. It is often the case that, when these other problems are addressed, the tinnitus is reduced. The therapist can help with this. If you have thoughts of harming yourself, then it is very important that you seek professional help.

Not only can a therapist bring objectivity and expert knowledge to your situation, but there is a strong therapeutic effect of having someone else listen to and understand your concerns in a warm and supportive atmosphere. The therapist will help to motivate you, as well as support you, in changing your reactions to tinnitus.

Because stress pushes us into middle-of-the-night thinking, we often end up having overly negative ideas about things like tinnitus. This is the same thing as inaccuracy or imbalance in thinking. CBT is not about ignoring the negative, but restoring the balance so that your ideas can be more accurate. Even though CBT acknowledges negative information, an accurate perspective should lead you to feel better than an overly negative one. Sometimes becoming aware of your thoughts and articulating them is enough to see that they are overly negative—causing you to reassess and change them. Often, however, the ideas need further consideration because they seem so compelling.

There are no rules about how you should further consider your ideas or achieve a balanced perspective. You can try anything you think may help you find out if your ideas are accurate, but some useful questions might include:

  • What evidence supports this idea?
  • What is the evidence this is not true?
  • What is the worst that could happen?
  • What would I say to a friend?
  • What would a friend say to me?
  • If I was not feeling so stressed what would I think?
  • Are there any other reasons why I might feel like this?

For example, when Bill recognized that one of the ideas troubling him was that he “could not enjoy life,” he set about looking at the evidence for and against this idea. First, he made a list of the evidence in support of the idea. He had felt tired recently and he had taken to his bed on a number of occasions. He found it hard to do some things that he normally found easy. He also felt anxious when entering noisy situations. Bill then made a list of things that did not support the idea. This included a list of times when he had enjoyed himself. He noted that he had enjoyed being with a friend and enjoyed gardening; he also enjoyed shopping with his wife; he managed to play with the children. All of this was not necessarily great, but it was ok.

Bill had to be careful of all-or-none thinking. Enjoying things to some extent, but not fully, is not the same as not enjoying them. Thinking in this careful way is important. By comparing his lists, Bill modified his belief that he did not enjoy things. His new idea was: “Things are not what they were but they are not all bad; I still enjoy quite a lot of things.” This idea was certainly less distressing than his original all-or-none thinking.

Writing down things has a more powerful effect than just trying to hold the ideas in your mind. Many negative thoughts can be addressed this way; you can weaken or break the hold that they have over you. The result will be less distress, less anxiety, and less focus on tinnitus.

Changing your behavior. Many ideas can be changed by the sort of careful reflection described above, but some ideas stubbornly remain. Sometimes a person can intellectually understand that his/her ideas are not accurate but nonetheless continue to be convinced by them (ie, knowing something with your head but not your heart).

Often the accuracy of a belief can be tested only by trying things out. Frequently this means doing things in a different way. Distressing ideas seem so compelling that we behave as if those ideas are true, and act in ways that we think will keep us “safe” by stopping a bad thing from happening or limiting our anxiety.

Unfortunately, keeping “safe” in this way helps to maintain middle-of-the-night thinking—fueling the distress and focus on tinnitus. Bill was told by his audiologist that everyday loud sounds would not damage his auditory system and would not worsen his tinnitus. He accepted this intellectually but still felt anxious about noise and avoided it. He also realized that his life had become very restricted, and he and his family were suffering. He was therefore faced with two competing viewpoints: his own and his audiologist’s. Ultimately, he believed it was worth the risk of testing out the ideas by going to a noisy place. If he was right and his tinnitus worsened, it would be awful. But, if his audiologist was right, his life would radically change for the better. He decided to go to the cinema knowing that the anxiety and focus on his tinnitus might make it a little worse temporarily. This is exactly what happened: The slight increase in the intrusiveness of his tinnitus was short-lived. He tried a few more similar experiments with equal success.

Bill now knew that everyday sounds were harmless; he knew this with his head and his heart. The restrictions on his life lifted and his focus on tinnitus disappeared. He still had tinnitus if he listened for it, but he no longer had a problem. Bill’s life radically improved, and he went back to work and, in due course, he came off his medications.

Testing your ideas by doing things differently leads to the most powerful change. Identify your distressing thought about tinnitus, and find out what you are doing to keep yourself “safe.” Work out what you could do differently that would test this idea.

Watch out for middle-of-the-night thinking when devising the experiment. All-or-nothing thinking can lead you to suppose extreme changes are needed to test your ideas; this is not necessarily so. Once you have decided on some changes, make some careful predictions about what will happen. Try things out and note exactly what does happen, and consider what the outcome means for your original idea. In a nutshell, act as your own therapist.

Changing anxiety level and mood. Anxiety levels can be reduced directly by learning and practicing some proper relaxation exercises. There are a number of approaches to therapeutic relaxation. We recommend learning progressive muscle relaxation. This involves gentle tensing and relaxing exercises that will change the state of affairs in your body.

Learning relaxation is something people learn early in therapy. Changing how you think about tinnitus, changing how you act, and practicing relaxation leads to changes in mood. Exercise will also improve mood (consult your doctor first).

Summary

Tinnitus is important not because it exists, but because of what you believe it does to you or will do to you. These ideas are not always accurate. If you change these ideas, you change your reaction to tinnitus and it will become less intrusive in your life.

Acknowledgement

This article was adapted with permission from the upcoming book The Consumer Handbook on Tinnitus, edited by Richard Tyler, PhD, available in spring 2008 from Auricle Ink Publishers, Sedona, Ariz (www.hearingproblems.com).

References

  1. Hallam RS, Rachman S, Hinchcliffe R. Psychological aspects of tinnitus. In: Rachman S, ed. Contributions to Medical Psychology. Vol 3. Oxford, UK: Pergamon Press; 1984:31-53.
  2. Andersson G, Baguley DM, McKenna L, McFerran DJ. Tinnitus: A Multidisciplinary Approach. London: Whurr; 2005.
  3. Hallam RS. Living with Tinnitus: Dealing With the Ringing In Your Ears. Wellingborough, UK: Thorsons; 1989.
  4. Henry J, Wilson P. Tinnitus. A Self-management Guide for the Ringing in Your Ears. Boston: Allyn & Bacon; 2002.
  5. McKenna L, Andersson G. Psychological aspects of hearing impairment and tinnitus. In: Luxon L, Furman JM, Martini A, Stephens D, eds. Textbook of Audiological Medicine. Clinical Aspects of Hearing and Balance. London: Martin Dunitz; 2003:593-601.

Citation for this article: McKenna L, Andersson G. Changing reactions to tinnitus. Hearing Review. 2007[Aug];14(9):12-19.

CORRESPONDENCE can be addressed to HR or Laurence McKenna, PhD, at [email protected]uk or Gerhard Andersson at [email protected]