Tinnitus habituation may be a term that you have heard if you are suffering from tinnitus. Tinnitus is when you perceive a sound, whether it is ringing, buzzing, hissing, roaring, or other sounds without the presence of a physical auditory stimulus within your environment. Tinnitus can be in one or both ears and can fluctuate in pitch or volume. Habituation is the process of becoming used to a stimulus and diminishing any associated negative emotions tied to that stimulus. Tinnitus habituation refers to the process of your brain becoming aware of your tinnitus, but learning to tune it out allows you to go about your day to day life.
The habituation process takes time and requires conscious effort, but occurs for all five of our senses. For vision, think about how often you lose common household items. You may have just been holding a pen, set it down on the desk in front of you, and when you glance down at the desk again you cannot find it. The pen has not moved, but your brain has become used to the placement of the pen. Therefore, it no longer thinks it is important and does not focus on it. For smell, a great example is if you are in the kitchen baking cookies before you have dinner with your family. When your family walks in, they will immediately smell the delicious aroma of the cookies. After saying hello and standing in the kitchen for 5-10 minutes, they will no longer smell the chocolate chip cookies baking. Again, our brain recognized the scent, decided that cookies are not dangerous, and physically tuned out the scent. For touch, this happens when you put clothes on in the morning. While you are getting dressed you immediately notice your shirt and pants, but as you start your daily routine you stop focusing on how the clothes feel on your skin. This ability to adapt to your surroundings is dependent on how your brain interprets and categorizes the sensory input. If it detects any form of danger, it will continually draw attention to the stimulus. If the pen had exploded ink all over your desk, your brain would divert your line of eyesight to notice. If while baking cookies you forgot about them and they started to burn, the smell of burnt cookies will stay until they are removed from the oven safely. When wearing clothes, if you have an annoying tag that keeps scratching your back, you will go throughout your day being continuously bothered by the feel of your shirt. This is how our brain treats tinnitus. The brain categorizes tinnitus as new and scary and tells our limbic system, which is responsible for our fight or flight response, to be overactivated. This overactivation creates the tense body reaction and negative feelings surrounding tinnitus. Just like with vision, scent, and sight we can teach our brain that tinnitus is not something we need to continuously focus on.
Impact Brain has on Tinnitus
Although it may sound impossible, your brain is able to tune out your tinnitus. Our brain is capable of two types of listening: active listening and passive listening. Active listening involves conscious effort and is used when we are paying attention and interacting with people or things within our environment. Watching television, talking to your spouse, listening to a school lecture all require active listening. Our ears pick up the sound information and our brain constantly comprehends the information and stores it within our memory. Passive listening occurs whenever we are not actively paying attention to something. Our brain is always aware of the sounds around us but chooses what to notice and what to ignore. Air conditioning, the refrigerator running, traffic noise are all sounds that never physically disappear. Our brains just recognize these sounds as not being important or new, therefore they do not pay attention to them. Tinnitus tricks our brain into active listening, and we need to retrain the brain to transition tinnitus into the passive listening category.
Tinnitus falls within active listening because, generally, sufferers tend to treat sound as an environmental danger, eliciting a fight or flight response. This fight or flight response creates a physical body reaction resulting in tension, stress, and annoyance. Once this physical body reaction starts, our body creates almost a reflex. Whenever it notices the tinnitus, the immediate response is to trigger the above physical body response. This cycle continues and grows until tinnitus becomes physically unbearable and interferes with daily activities. Our brains simply cannot tell the difference between real danger and an imagined/phantom threat, like tinnitus. The goal of tinnitus habituation is to teach our brain that tinnitus is not a threat to our safety. We do this through teaching our brain about the auditory system, how tinnitus is generated, and how sound is beneficial to our overall health. This is known as Tinnitus Retraining Therapy (TRT) and was developed by Pawel Jastreboff. TRT involves counseling on the three parts of the ear and how each transmit sound waves to be interpreted by our brain. It also discusses the central auditory pathways and how these influence the severity of tinnitus. TRT teaches us that sound alone is not the cause of tinnitus and how to react in a neutral manner to sound. This can be done through multiple counseling sessions, meditation and relaxation techniques or through sound therapy.
Treatment
Sound therapy is one common form of treatment option used for tinnitus. Sound therapy works by providing therapeutic sound directly to the ears, teaching the brain and the limbic system that it has access to sound and that sound is beneficial. Sound therapy allows our brain to focus on sounds that are pleasant and start to learn to ignore the tinnitus. We often refer to elevator music to help explain this concept. When you walk into an elevator, you may immediately notice the soft tune playing in the background. It is not loud or the number one song played on the radio. Instead, it is often soft and relaxing and will quickly fade into the background. This is how we want to treat tinnitus, as elevator music. Sound therapy works by introducing noise directly into your ears, whether that be through headphones, your phone, or hearing aids. The goal is to blend this noise with the tinnitus, allowing your sound to still be audible but overall, less bothersome. The goal is not to completely block out your tinnitus with masking, as this has no long-term validity in terms of treatment success. Often people ask why adding more sound is beneficial, because they believe all sounds will be as bothersome as their own tinnitus. I use the example of an orchestra to explain this. If you attended a concert and only a single violin was playing every piece, you may start to become annoyed by the violin. If we add in other instruments, they all start to blend together to form a beautiful sound. Your tinnitus is the violin. It is bothersome, annoying, and a single sound. By adding another sound through sound therapy, we are adding in the rest of the orchestra. For sound therapy, specific noise is used as well. The most common are either low-level steady state noise or fractal noise. Steady state noise is white noise, or what people often think of as static noise. Fractal sounds follow no identifiable pattern and examples include nature and water sounds. This therapeutic sound can be present throughout the entire day, or only when your tinnitus becomes bothersome. Often many patients with tinnitus will start and end their day with sound therapy as their tinnitus becomes most bothersome when they first wake up and when they are trying to fall asleep at night. Overall, the goal of sound therapy is to teach our brain and limbic system that sound is good and to start filtering out the bothersome tinnitus. As I mentioned earlier, sound therapy should not be bothersome or annoying. The noise used should create neutral reactions from your limbic system and give you full emotional control. Along with your audiologist, you will set the volume of the sound therapy. It should be loud enough to be consistently heard throughout your day, but not mask your tinnitus sound completely. It should not interfere with your daily activities or communication, and if streamed directly into your ears, should not be audible to those around you.
Hearing aids are also a great tool to assist in the treatment of tinnitus when it is associated with hearing loss. Hearing loss is treated with amplification that is fit specifically to one’s ear anatomy and severity of the hearing loss. Although sound therapy uses therapeutic sound and is beneficial to our ears and brain, this does not manage hearing loss. For patients who have both conditions, you may only need to focus on one form of intervention. For 60% of patients with both tinnitus and hearing loss, both conditions are effectively treated by consistently using hearing aids. Wearing well fit hearing aids enriches the listener’s environment with sounds, allowing the brain more auditory stimulus. This often can help resolve the tinnitus, even without further intervention. If you do not have hearing loss, there are many phone apps that can be used for sound therapy as well. Resound Tinnitus Relief is a great app that offers a wide variety of natural sounds, deep breathing exercises, and guided meditation to support tinnitus treatment. The Widex Zen app is another great option. This hearing aid manufacturer created six different combinations of fractal Zen tones that aim to relax our body and limbic system. These are more representative of music, as each has a specific melody, timbre, and tempo. If you are bothered by traditional static noise or natural sounds, this may be a better option for you, if pursuing sound therapy.
Habituation Process
Although the habituation process can be long, the amount of time needed for our brain to complete this varies for everyone. It will be life changing once complete. Many individuals who completed TRT, tinnitus counseling, and sound therapy state that it has changed their lives. They can interact with loved ones again, can return to work, and rejoin hobby groups that they were once able to attend. Tinnitus at one time took these things away from them, but after habituation, were able to take control again. Once habituation occurs though, it is important to recognize that you cannot immediately quit your therapy. If you were to do this, the tinnitus would return, and the entire cycle would start again. Talk with your audiologist about what therapies you should continue and which ones you can start to remove from your daily life. Typically, sound therapy is something that can be used consistently everyday without harm. Meditation and relaxation techniques can usually be stopped if the added stress from your tinnitus has been removed. All of the tools you were provided to help with tinnitus are always available and you can easily add them back into your daily routine.
Tinnitus habituation is often a difficult process and will require help from your family and your medical/health professionals. It is important to remember that habituation will not happen overnight and can include highs and lows. Once you teach your brain that tinnitus is not scary or new, it will quickly learn to stop constantly focusing and alerting you to it. This habituation will allow you to take back control of your life and enjoy being around sound again!
