ACO Guidelines Recommend CBT for Chronic Tinnitus

CBS news reported yesterday that the American College of Otolaryngology (ear, nose, and throat docs) recently released updated guidelines on the treatment of chronic tinnitus. Tinnitus is a persistent ringing in the ears, though it also can include other sounds, such as buzzing or whooshing. It is a relatively common condition, especially among combat veterans and other individuals who have been exposed to exceedingly loud sounds.

As you might expect, most of the recommendations pertained to things that audiologists and ENT's care about, such as hearing aid evaluations and audiologic exams. But, they also made recommendations about other treatment modalities. Specifically, they recommended against antidepressants, dietary supplements, and transcranial magnetic stimulation (TMS) for the treatment of "persistent, bothersome tinnitus." Instead, they recommended cognitive behavioral therapy.

At first blush, CBT or other psychological approaches may seem inappropriate for the treatment of a condition that appears so purely physical. Indeed, when I've worked with people who have persistent tinnitus, I've always recommended they seek a medical or audiological exam, because tinnitus can be a sign of other problems, such as noise-induced hearing loss.

But tinnitus, like chronic pain, or irritable bowel syndrome, is a medical problem with a strong emotional component. And as such, it can be well managed via CBT.

At its core, CBT works by helping a person to disentangle the ringing itself from the emotional and cognitive reactions to the ringing. Ringing in the ears is actually not uncommon. Anybody, in a quiet enough environment (such as an audiology booth), will experience ringing, or other auditory phenomena. These are technically hallucinations, but they are not unusual or harmful. It's just what our brains do. In the absence of a perceptual signal, your brain spontaneously creates one. (This happens in your visual field, too. Close your eyes tightly, and you'll continue to "see" lights and other things)

The ringing is, in and of itself, inert. Neutral. No problem. It's a constant signal that delivers no information. Our brains are wired to generally habituate to these types of stimuli. This is why, even though you can hear the steady hum of an air conditioner, you generally don't. Even if you notice it momentarily, it doesn't warrant further attention, so your brain filters out the signal. That is, until the AC motor clicks off, and then you notice whatever other noise was previously blocked out by the hum. Our brains are built to attend to change, and to disregard the constant.

So, if you suffer from tinnitus, why doesn't your brain just filter out the steady, meaningless ringing?

It's because of your emotional reaction to it. Imagine, for a second, that you believed that the hum of the AC unit meant something awful was going to happen. You'd got it in your head that the AC sound was going to drive you crazy, and that it was never going to end. Or, maybe you associated that sound with some awful past event. In any case, you hate that sound, and you'd give anything never to hear it again.

If that's what you thought, hearing that sound would give you a jolt of frustration, anxiety, maybe even terror. There it is again! It's driving me nuts! Your attention would be hijacked, and held captive by an essentially meaningless sound. You might even stop whatever you're doing, and notice the sound and wait for it to go away. And the more you noticed it, the louder it would seem. Eventually, you might feel hopeless, or even depressed.

This, I think, is the cycle that many tinnitus sufferers fall into. And when they look for solutions, they find offers for supplements, sound machines, and other "cures" that reinforce the idea that the ringing is a problem that needs to be solved. Which only makes it worse. 

This is why an acceptance-based, cognitive-behavioral approach to tinnitus can be so helpful. When you see how your instinctive reactions actually make it worse, you acquire the freedom to respond differently. When you see how your attention is hijacked, you can learn to refocus it in a more helpful way. You stop avoiding the ringing, and you allow yourself to just be with it, without fighting it, until it's no longer a problem. At which point, it effectively goes away.

If you're in the throes of struggling with tinnitus, this approach might seem ridiculous. You might scoff at the idea of ever "just accepting" the ringing. But it's completely doable. And that's what therapy is for: Helping you do it.