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Tinnitus Management

Tinnitus Management

What is Tinnitus
How comon

Treatment is individually tailored to your needs and sound therapy and specialised directive counselling are incorporated as required.

We offer help with relaxation, general life-style and stress management for additional support.

Tinnitus management is provided for both adults and children. Please obtain a referral from your GP or other medical specialist prior to arranging an appointment.

 

What is tinnitus

Tinnitus is simply the name for noises in the head or ears – the word is derived from the Latin “Tinnare” which means “to ring”. It refers to any sound that is heard in your head or ears, for which there is no external source or explanation.

 

Many people are aware of tinnitus if they are in an extremely quiet room. In an experiment some years ago most medical students placed in a sound proofed room became aware of tinnitus that they had never heard before whilst in the room.

 

Occasionally there is a physical cause, however in most cases there is not. Tinnitus management is extremely helpful, allowing tinnitus to be filtered out and not heard. We do not recommend any specific surgical or medical interventions except in a tiny minority of cases.

 

How common is it?

Tinnitus has been described for as long as humans can write. It is extremely common - around 30% of the adult population of the UK have heard it at some time, 10% for prolonged periods, and of these people about 4% consult their GPs about tinnitus. Significant tinnitus distress is far less common, however for an important minority of people it can be loud, annoying, intrusive and life changing.

What causes it?
What causes tinnitus

What causes it?

Tinnitus often is one of the first signs of a hearing loss. Hearing aids can be extremely helpful. However, it can also occur in people with normal hearing.

 

It is also very common after loud noise, for example a night out with amplified music. Noise induced tinnitus often disappears within a few hours to a few days but can be a sign that the sound was too loud.

 

There are many other causes of tinnitus. If your tinnitus is associated with pain, facial weakness, changes in your balance, or sudden hearing loss you should seek medical help as soon as possible. However, in most cases tinnitus is not a symptom of anything seriously wrong with you.

Common causes include:
  • Loud noise

  • Ear Wax

  • Hearing Loss

  • Ear infections

  • Ear trauma

  • Stress and anxiety

  • Low mood state

  • A traumatic life event

Does it affect children adult
Where does tinnitus come from?

Does it affect both adults and children?

Both adults and children experience tinnitus, although many children simply regard it as normal. If your child is concerned about it, then we recommend arranging an appointment to assess the problem and give both you and your child some reassurance and advice.

 

Where does tinnitus come from?

For years researchers have tried to identify the exact location of tinnitus, with the chief suspect seen as the internal ear, or cochlear. In fact, the picture is much more complicated than that, and it is far more likely that tinnitus is a result of hearing ambient sound within the auditory pathways, that would normally be ignored. You are more likely to hear this sound if you have a hearing loss.

About auditory filters

To hear tinnitus, it needs to get through the auditory filters

The auditory system, in common with other sensory systems, performs an enormous amount of analysis of sound before we become aware of it, and only a tiny percentage of the sounds around us ever reach our conscious awareness.

Our brains are amazing! When you walk down a street, or go for a stroll in the country, you are surrounded by millions of different sounds, sights, smells and physical stimuli. However, you are not aware of all of these – your brain selectively attends to what is important to you and ignores what it decides is not. It habituates to unimportant stimuli and tunes in to important ones.

 

Our brains use a complex sound filtering system to do this. These filters are influenced by parts of the brain that manage our emotional response and alertness to sound. This wonderful system is there to keep us safe and happy. So, anything that we really love, or really hate, or perceive as a threat to our life or life quality will pass through the sound filters even if it is very soft, or only partially heard.

 

This filtering system relies on the relationship between the auditory system, and the parts of the brain that mediate our emotional response to sound, our alerting response to sound, and our physical response to sound (the limbic, reticular activating and autonomic nervous systems).

 

When we hear sound for the first time we learn its importance, and therefore its meaning to us. Meaningless irrelevant sound is filtered out, but important sound will be heard even if it is very soft. 

Tinnitus retraining therapy

Our Tinnitus management program adheres to Tinnitus Retraining Therapy guidelines. Treatment is individually tailored to your needs and sound therapy and specialised directive counselling are incorporated as required. We offer help with relaxation, general life-style and stress management for additional support.

Tinnitus Retraining Therapy is based on the neurophysiological model of tinnitus proposed by Pawel Jastreboff in 1990. He and his colleagues worked closely with Jonathan Hazell and his colleagues to develop the clinical programme called Tinnitus Retraining Therapy. Jastreboff’s neurophysiological model is shown below.

Auditory & other cortical areas
Habituation to tinnitus

Put very simply, the theory is that a very weak tinnitus signal arises in the auditory periphery (the source of tinnitus). This is detected and processed within the auditory subconscious. At this point it can either be filtered out or sent on to the auditory and other cortical areas involved in sound perception. Of course, we don’t just hear tinnitus, we evaluate it.

 

Our evaluation may be that this is a new sound, never heard before, but not a problem. In this case it will probably be filtered out and we won’t hear it after a while. This is what normally happens.

 

However, if this new sound is concerning to us, or we are worried about the cause, the limbic system, which mediates our emotional response to sound, fires up and tells the auditory subconscious to listen out for tinnitus. We pay it more attention, we have a stronger reactions to it, and we hear it more. 

 

Habituation to tinnitus

Tinnitus therapy teaches you to habituate to tinnitus by retraining your brain not to pass tinnitus signals through your auditory filters. If you habituate to tinnitus, you will be less troubled by it, hear it less and less, find that it is a meaningless background sound, and may even find that it disappears completely.

 

The aim is not complete absence of tinnitus for everyone, although some people become almost unaware of their tinnitus in a day-to-day environment. You may still hear your tinnitus if it is particularly quiet around you, if you are focusing on it, or if you are particularly stressed or anxious.

 

Most people habituate to their tinnitus on their own, but if this is not happening then tinnitus therapy is extremely effective.

Breaking the vicious circle

You wake up and hear your tinnitus. You feel anxious about it, and start to catastrophise, thinking that it will never change and you will have it forever. You then start to panic about how you and those around you will cope. Before you know it the tinnitus is louder than ever, you feel more anxious about it, engage in more catastrophic thinking, become more panicky, the tinnitus seems louder and voila – the vicious circle has you firmly in its grasp.

 

The problem is that this tunes your auditory system into tinnitus, whereas for your tinnitus to improve the opposite needs to happen – you need to learn to filter out tinnitus. So it is important to avoid vicious circles, and break them whenever you realise that you are in one.

 

In time you will learn to filter your tinnitus out, also called habituating to it, but in the meantime try the following:

 

  • Some low-level background sound, a little softer than the tinnitus

  • Repeat a nonsense word to yourself like “na” then count backwards from 21 in 3s, or 48 in 2s, or something that is mildly absorbing to distract yourself

  • Focus your mind on a pleasant memory – imagine the sounds, sights, smells and physical sensations

  • Try some deep, controlled breathing – in for two, out for two

  • tighten then relaxing various parts of your body, holding the tightness for a count of 10 before releasing

  • Try to think about the tinnitus in a rational way, remembering scientific information about it rather than focusing on your own thoughts about it

  • Plan your day step by step – it is important to have a daily routine

  • Get out of bed, start these steps, and then reward yourself with something you enjoy

  • Keep yourself mentally and physically active – live life as fully as you can

Breaking the vicious circle

Tinnitus therapy ingredients

There are many approaches to tinnitus management, and a google search will reveal all sorts of things. Researching tinnitus has been likened to trying to make an itch scientific – we rely almost totally on subjective report. It is also likely that there are many different types of tinnitus lumped together under the term “tinnitus”, so whilst alternative therapies that promote relaxation might work better for individuals whose tinnitus is mainly stress related, they don’t do much to manage the effects of hearing loss and so on.

 

Meta-analysis of tinnitus studies suggests that a combination of psychological management and sound therapy is most effective. The term psychological management here is used to include basic information giving about tinnitus, counselling and more intensive strategies such as cognitive behavioural therapy.

 

So, there are many ways to cook an omelette, however the ingredients remain the same.

Tinnitus management is very much a “whole person” approach – ignoring emotional state and general health issues is not helpful.

How does tinnitus therapy work?

How does tinnitus therapy work?

Crucially for tinnitus management, the filtering system in the auditory subconscious is dynamic and not hard wired. It is this filtering system that can be re-set, or re-trained with tinnitus management.

 

If you have a hearing loss, we recommend appropriate hearing aids. We also discuss sound therapy, which can help you to filter out tinnitus.

 

We also help you to understand your tinnitus, what it is, why it is there, and what is keeping it there. This is the first step to changing your thoughts and beliefs about tinnitus, and this in turn allows the limbic system to become less reactive towards tinnitus. We work with you to identify and manage any unhelpful thinking distortions you may have about tinnitus, and to help you think about it less. Relaxation plays a crucial role.

How does tinnitus therapy work?

Patient journey

The first step is to identify what is going on. We take a careful case history before checking your hearing. It is really important for us to understand what effect the tinnitus is having on you, how it makes you feel, and if you are suffering from any consequences such as anxiety or depression. We also ask about the effects of tinnitus on your life quality, including on your sleep.

We then discuss our findings with you, with the aim of giving you a clear understanding of what is, and as importantly, what is not, the problem.

 

This may be enough, however for troublesome tinnitus we then arrange a series of 5 - 6 appointments over a six month period, longer term reviews thereafter as necessary.

 

Management tends to consist of frequent initial sessions, followed by an increasing length of time between appointments. The aim is to give you a toolbox that can be used at home, rather than relying just on management sessions.

 

If you have a hearing loss we recommend appropriate hearing aids. We also discuss sound therapy options. Habituation strategies including changing negative thinking and relaxation are introduced in each session.

 

Long term reviews are important. It is very difficult to do all of this on one’s own, particularly if something changes and you become aware of tinnitus again.

 

We provide tinnitus management for both adults and children. We ask that you see your GP or other medical specialist prior to arranging an appointment with us in order to exclude any conditions that need medical or surgical management.

Hearing aids for tinnitus

Hearing aids for tinnitus

There have been tremendous advancements in the field of hearing technology. From ear trumpets, through to tiny ear-level computers that fall into the category of wearable technology. Optimizing hearing reduces straining to hear, stress and anxiety, and feelings of social isolation.

 

Better hearing also normalizes the sound level to the ear, reducing contrast between internal tinnitus and external sounds. In some cases additional sound therapy may be required to do this, either via wearable sound generators if the hearing is normal, or via a combination of amplified sound and sound therapy.

Sound therapy for tinnitus

Advice on sound therapy is given at each appointment, and when appropriate wearable sound generators are fitted.

Sound therapy can be very effective for managing tinnitus and hyperacusis, but it is not usually a long-term treatment. It refers to having a soft meaningless sound around you for extended periods of time, and this can be either from a tabletop speaker, or from wearable sound generators.  Many people find it very helpful at night. Sound therapy can be used for individuals with normal hearing, and those with hearing loss.

Sound therapy for tinnitus

Sound therapy may appear to be counter-intuitive – why on earth would you want another sound! However, to draw a visual analogy, look at these picture of washers. Imagine that each one represents a sound in your environment. The single washer is obvious, but far less so when amongst a sea of washers.

 

In other words, tinnitus is relatively loud when it is the only sound, but far less so when it is one of many. So sound therapy helps to make tinnitus less obvious.

 

The sound used for sound therapy should be neutral, meaningless, and as broad frequency as possible. White noise, or nature sounds are much better than the radio or television. Set the sound therapy so that it is just below the level of your tinnitus, or just starting to mix in with it. You want to hear some of the tinnitus, but less of it, but please note that you are not trying to mask, or drown out, your tinnitus. If the sound therapy is too loud, turn it down – it should never be annoying or intrusive.

 

Think of sound therapy as reducing the perceptual contrast between a target sound, and environmental sound. In a quiet home environment, these target household sounds can be quite distinct. The same sounds during the day are hardly heard as the background noise level is so much greater.

 

In the same way, if you are in a very quiet environment you will be hyper-aware of your tinnitus.

 

Sound therapy aims to increase ambient sound levels so that tinnitus is less obvious. There is much debate regarding the best form of sound, however there is little evidence that expensive individually filtered sounds are any better than broad band rushing sound. What is important is that the sound should not mask tinnitus for 3 main reasons:

  • The brain picks out the tinnitus from the masking sound, creating a chasing effect

  • Replacing one sound with another is not a viable solution

  • You cannot learn to habituate to a sound that you no longer hear

Common cognitive distortions

Negative thinking about tinnitus

Cognitive distortions are ways that our mind convinces us of something that isn’t really true. These inaccurate thoughts are usually used to reinforce negative thinking or emotions — telling ourselves things that sound rational and accurate, but only serve to keep us feeling bad about tinnitus. Of course, the worse you feel about tinnitus, the more likely you are to find it intrusive.

For instance, a person might tell themselves, “If I hear tinnitus it will be dreadful. If I stop hearing tinnitus it will be wonderful”. This is an example of “black or white” (or polarized) thinking. The person is only seeing things in absolutes — that any tinnitus that they hear is awful and not hearing tinnitus is the only way forward.

 

Of course, the aim of retraining therapy is to change these thinking distortions about tinnitus, leading to becoming less reactive to tinnitus, and thereby promoting filtering it out or habituating to it. If this happens, you will become less aware of your tinnitus, and less troubled by it if you do hear it.

 

By learning to correctly identify negative thinking about tinnitus you can then answer the negative thinking back and refute it. By refuting the negative thinking repeatedly, and replacing it with thoughtful reactions based on facts, negative thinking will slowly diminish over time and be automatically replaced by more rational, balanced thinking. If this happens, you can start to habituate to tinnitus.

 

Common cognitive distortions

In 1976, psychologist Aaron Beck first proposed the theory behind cognitive distortions and in the 1980s, David Burns was responsible for popularizing it with common names and examples for the distortions. Some of the common ones that apply to negative thinking about tinnitus are listed below.

​1. Filtering

 A person engaging in mental filtering takes the negative details and magnifies those details while filtering out all positive aspects of a situation. For instance, a person may pick out a single, unpleasant detail about their tinnitus and dwell on it exclusively so that their vision of reality becomes darkened or distorted. When a cognitive filter is applied, the person sees only the negative and ignores anything positive.

​2. Polarized Thinking (or “Black and White” Thinking)

In polarized thinking, things are either “black-or-white” — all or nothing. We have to be perfect or we’re a complete and abject failure — there is no middle ground. For Example, “I can’t lead a normal life until my tinnitus goes away completely.”

A person with polarized thinking places people, situations or tinnitus in “either/or” categories, with no shades of grey or allowing for the complexity of most people and most situations. A person with black-and-white thinking sees things only in extremes.

​3. Overgeneralization

In this cognitive distortion, a person comes to a general conclusion based on a single incident or a single piece of evidence. If something bad happens just once, they expect it to happen over and over again. A person may see a single, unpleasant event as part of a never-ending pattern of defeat.

For instance, if you have a period of time when the tinnitus is particularly intrusive, you assume that it will always be like that and you will never get better.

A big part of overgeneralising is projecting into the future – how my tinnitus is now is how it will always be.

4. Catastrophizing

When a person engages in catastrophizing, they expect disaster to strike, no matter what. This is also referred to as magnifying, and can also come out in its opposite behavior, minimizing. In this distortion, a person hears about tinnitus and uses what if questions (e.g., “What if my tinnitus gets worse?” “What will happen to me?”) to imagine the absolute worst occurring.

 

For example, a person might exaggerate the importance of insignificant events (such as a slight change in their tinnitus). Or they may inappropriately shrink the magnitude of significant events until they appear tiny (for example, not acknowledge success in changing beliefs, or using relaxation techniques regularly).

5. Magnification and Minimisation

This is where we give weight to negative thoughts or experiences, and completely minimise the positive ones. For example, when people have episodes of habituation to tinnitus, followed by periods of troublesome tinnitus, they tend to focus on the troublesome times and completely ignore the huge step forward that periods of habituation to tinnitus represent.

With practice, you can learn to answer each of these cognitive distortions.

The effects of negative thinking about tinnitus

The effects of negative thinking about tinnitus 

The main effects of negative thinking about tinnitus are changes in our emotional state, and changes in our behaviour towards tinnitus.

Cognitive distortions don’t only affect how we think about tinnitus, they affect how we feel. People whose thinking is distorted, commonly find that the distortions make them feel depressed, anxious and / or angry. These feelings can make people react in unexpected ways – feeling depressed about life in general, feeling anxious and as if they can’t cope, or feeling angry with either yourself or those around you.

 

These feelings do several things – firstly they increase our awareness of tinnitus, secondly they increase the sensitivity of the auditory filtering system to tinnitus, and thirdly they enhance our thinking distortions. Monitoring behaviour often occurs – people become obsessed with whether they can hear their tinnitus, and how loud their tinnitus appears to be.

 

The result of this is that the auditory system tunes into tinnitus very strongly, as tinnitus now appears to be a threat to your life quality – a vicious circle occurs.

 

So, it is important not just to identify how thinking is distorted, but also how these thoughts make you feel and behave.

What to do about negative thinking 

Our tinnitus management aims to help you to understand tinnitus as a very weak signal that is amplified within the auditory pathways because of the way that you are thinking about it and reacting to it. We help you to identify the cognitive distortions that are taking place and talk them through with you.

 

Ask yourself:
  • What is the evidence for thinking the way I do?

  • Are there any alternative views – what would someone else think?

  • What is the effect of this cognitive distortion?

  • Can I alter the way I think to something more rational and balanced?

 

Remember, you are aiming to hear tinnitus but not engage in negative thinking about it. The more you can do this, the quicker you will habituate to it, and the more your tinnitus will be filtered out as meaningless.

 

Try the following:

1. Write down one negative thought about tinnitus

2. Identify how this makes you feel and behave – this is the effect of the negative thought

3. Challenge your thought –

  • “What is my evidence”

  • “Is this the whole story, or am I focussing on one negative event and ignoring any more positive ones”

  • “Is there another way of looking at this”

  • “What would someone else think”

  • “How does this fit with my understanding of the neurophysiological or tinnitus habituation model”

​4. Challenge the cognitive distortion until you are thinking about your tinnitus in a more rational and balanced way

 

Try to do this regularly every day. It may be hard at first, but do keep trying – negative thoughts take time to change, and bad thinking habits need hard work.

Relaxation techniques

Relaxation techniques

Following are four relaxation techniques that can help you relax and reduce stress. The idea is to feel relaxed whilst you hear tinnitus, rather than becoming anxious and stressed by it. This sends a very powerful message to your mind and body that it is OK to hear tinnitus, and to start filtering it out as a meaningless sound.

To begin with, you may only be able to do this for brief periods of time – do what you can. But keep going and try to relax every day building up from a few minutes, to around 20 minutes at a time. The longer and the more often you practice these relaxation techniques, the greater the benefits, the more you can reduce stress and the more you can teach yourself to habituate to your tinnitus.

If you find it hard to do this in a quiet environment, have some gentle background sound around you. There are many apps and online recordings of nature sounds – pick a couple that work for you and alternate them so that you don’t get bored. The background sound should be slightly softer than your tinnitus, never louder.

1. Breath focus

In this simple, powerful technique, you take long, slow, deep breaths (also known as abdominal or belly breathing). As you breathe, you gently disengage your mind from distracting thoughts and sensations. However, if you find this difficult, just focus on breathing a bit slower and a bit more deeply than normal.

2. Body scan

This technique blends breath focus with progressive muscle relaxation. After a few minutes of deep breathing, you focus on one part of the body or group of muscles at a time and mentally releasing any physical tension you feel there. If you find it difficult to just let go of the tension, try gently tightening that muscle group for a slow count of 5 and then let go. A body scan can help boost your awareness of the mind-body connection.

3. Guided imagery

For this technique, you conjure up soothing scenes, places, or experiences in your mind to help you relax and focus. You can find free apps and online recordings of calming scenes—just make sure to choose imagery you find soothing and that has personal significance. Guided imagery may help you reinforce a positive vision of yourself, but it can be difficult for those who have intrusive thoughts or find it hard to conjure up mental images. If mental images are hard, have a photo or an object that you can focus on that reminds you of pleasant experiences.

4. Mindfulness meditation

This practice involves sitting comfortably, focusing on your breathing, and bringing your mind's attention to the present moment without drifting into concerns about the past or the future. This form of meditation has enjoyed increasing popularity in recent years.

Rather than choosing just one technique, sample several to see which one works best for you.

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