Tinnitus Group Information Booklet

Northern Lincolnshireand Goole

NHS Foundation Trust

Kindness • Courage • Respect

Understanding and Managing Tinnitus

Tinnitus is defined as the perception of a sound when there is no external cause. Statistics vary, but in the UK between 35-45% of adults are aware of some sort of tinnitus (the percentage increases in the over 50s); 8% experience tinnitus that interferes with sleep or causes moderate annoyance and 0.5-1% report severe tinnitus that affects their ability to lead a normal life.

Tinnitus has been described as a phenomenon for thousands of years: the Ancient Egyptians, the Romans and the Greeks have all written about it. Beethoven had it and Darwin kept a daily record of his tinnitus. So it is not just a modern complaint and, since it has been with us for such a long time, it is not surprising that there have been many suggested remedies for it over the years. For example, Pliny proposed the use of earthworms boiled in goose grease. A very brief search of the internet these days will bring up a plethora of supposed “cures” which are probably about as effective as this, but no doubt a lot more expensive.

Tinnitus is very diverse in character and cause and so doctors may find it difficult to trace a link between the emergence of the tinnitus and any specific pathology. Indeed, it may present in association with altered emotional or psychological states following trauma which may, or may not have an audiological element. Therefore,tinnitus should not be viewed as a specific symptom in itself.

How we hear

Our ears act as sensors, bringing in information from the outside world in the form of vibrations. They then convert this mechanical information into an electrochemical signal and send it to the brain for it to be processed and interpreted. It is therefore important to understand that all meaningful hearing actually takes place in the brain, not the ear itself. That means that we also have to learn how to do it.

While in the womb, an infant brain begins to register external sounds very early on. It then needs to form connections between nerve fibres to give those sounds meaning. In this way, they form pathways that involve not only the auditory (orhearing) centres of the brain, but also those involved with emotion and alarmresponses. As the child grows and develops an increased understanding of thesounds and their significance, it can begin to learn how to react appropriately andbegin to acquire speech and language. At around the age of 2, the child also learns that it can choose how it will react to sounds, so it may or may not obey instructions for example or ignore adult conversation, but be immediately alert to the sound of a sweet wrapper!

This process continues throughout our lives, becoming increasingly automated so that we are able to “filter out” certain sounds (habituation) and respond to others. We could not function if we were fully aware of each and every stimulus in our environment at any given moment. However, if one such stimulus should change, then it will trigger alertness in our brain. For example, we learn to ignore the sound of traffic passing in the street, but if a vehicle slows to pull up outside our house, we are instantly curious.

The Importance of Sound

Up to now, we have looked at the brain’s reaction to sound, but what about its reaction to an absence of sound? In nature, silence is an alarm signal - the calm before the storm. For example, during the 2011 earthquake in New Zealand, people noticed that the birds all stopped singing approximately 10 minutes before the tremors hit.

When the brain becomes aware of a sudden or gradual silence, it increases its stateof arousal. This turns up the central auditory gain which makes any sound detectedat this stage appear louder than it would normally. You may have noticed that acreaky floorboard seems much louder in the dead of night than it does during theday

The Heller and Bergman experiment of 1953 elegantly illustrates this. A group ofstudents with normal hearing and no tinnitus perception were asked to perform a hearing test in a soundproof room. Despite the fact that no sounds were presented, 94% of them pressed the response button and reported hearing sounds that we would recognise as tinnitus. The conclusion was that they had become aware of the random (or baseline) electrical activity in the auditory system. Central auditory gain also helps us to listen to one speaker or sound and ignore another. Furthermore, we can hone this skill in pursuit of our interests: musicians, car mechanics, radio hams and bird watchers are all making use of this phenomenon.

When we first become aware of tinnitus, it is a change to our normal state, and theconscious part of the brain (our thought processes) become involved. Becausepeople often associate noises in the head with hearing loss, brain tumours or evenpsychosis, anxiety about its cause can further increase the brain’s arousal which, inturn, increases central auditory gain. In some cases, it may trigger a survival reflexand we experience a surge of adrenalin: the so-called fight or flight response. Thisis something that the brain will not allow us to ignore.

Unfortunately, many people who experience tinnitus are often met with littleunderstanding when they first approach their doctor for help. They may simply bedismissed or given unhelpful and incorrect advice “It won’t go away, you need tolearn to live with it.” This, combined with the fact that tinnitus often first presents at a time when the brain is in a heightened state of arousal, can lead to an increase inanxiety and cause people to feel that something must be very wrong and that theycan’t cope.

If this happens, the brain assesses the tinnitus as a potential threat and begins tomonitor it. This repetitive checking creates a short-cut in the neural pathways linkingawareness of the sound and the emotional response. There may also be an overallincrease of sensitivity in the auditory pathway. All of this maintains the tinnitus andmakes it appear louder.

The Good News

The good news is that this whole process has been learnt and so can, therefore, be reversed by re-training. The first step is to lose the fear factor. There is evidence to show that if the person with tinnitus is taken seriously in the first place and given a thorough medical examination to rule out any sinister pathology, then they can be given accurate and reassuring information at an early stage. This is vital to prevent the formation of that short-cut in the brain between the sound and a negative emotional response. IF the underlying fear is taken away, often we lose the survival reflex, which gives the brain permission to start the process of habituation and allows the tinnitus to fade into the background.

Most patients are desperately seeking cures or a way to make the tinnitus stop. This is what we call tinnitus-related activity. It focuses attention on the tinnitus and so again maintains the use of that shortcut in the brain. If we can lose the fear of the tinnitus and accept that it is an artefact of a normal-functioning auditory system, then the unhelpful shortcut falls out of use; the sensitivity in the auditory pathway reduces; the central gain is turned down and we learn that, although the tinnitus is still audible, it is “safe” to ignore it.

It is possible to speed up this process by avoiding silence and using other sounds to reduce the contrast between a quiet room and the tinnitus. This is called sound enrichment and may involve using everyday environmental sounds, noise generators of various types, or hearing aids. These sounds are not supposed to mask or cover up the tinnitus, but lessen the silence of the surroundings. It doesn’t matter whether the tinnitus is still there, the important thing is that it becomes less significant and no longer affects the quality of life.

Conclusion

The crucial point, then is that it is not the source of the tinnitus, or even the sound itself that is important, but the interpretation of or attitude towards it. If you understand how you use your hearing in everyday life, then you will see how the attention and your reaction to sound varies with emotional changes and sensations of well-being.

In essence, the person with tinnitus should

• Avoid quietness

• Stop the checking process

• Let the medical professionals take care of diagnosis.

In other words, don’t do anything for, or because of your tinnitus!

Taming Tinnitus - Behavioural Techniques

Vickie House, Dr Laurence McKenna & Dr David Scott - Psychologists, The Royal Throat, Nose and Ear Hospital, London

Do you feel sometimes that your tinnitus is ‘in control’? Many people do. At times like this, it can be difficult to imagine that there are ways of turning the tables and managing your response to tinnitus. Whilst there is currently no known ‘cure’ for tinnitus, there are a range of strategies that can help to minimise the intrusiveness of the noises. People can and do manage the impact that tinnitus has on their lives. Here are some ideas.

Making the tinnitus less ‘attention-grabbing’

Research shows that, whilst a large percentage of the population have tinnitus noises, a much smaller percentage are generally aware of them or distressed by them. This is because people are often able to get used to the noises or ‘habituate’ to them – just as we can often get used to other noises around us (e.g. air conditioning or a clock ticking). In general, the noises we are most able to ignore are predictable, repetitive sounds that we perceive as non-threatening, uninteresting, and unimportant. We are also more able to direct what we pay attention to when we are more relaxed. Here are some ideas for starving tinnitus of attention:

Do

• Notice in which environments and during which activities the tinnitus is less noticeable. Try to do more of the activities that help to shift your attention from the tinnitus (these will probably be activities you enjoy or are interested in). Expect the noises to be more noticeable in some environments (e.g. where there is less background noise). If possible, try to find ways of making these environments less ‘tinnitus friendly’ (e.g. introducing some low-level sound).

• Practice slowing down your breathing and relaxing your muscles every day (perhaps try a warm bath, muscle relaxation exercises, or a massage)

• Take some time each day to practice switching your attention between the tinnitus noises and other bodily sensations. For example, close your eyes and take a couple of minutes to focus on the rhythm of your breathing, then switch your attention to your hands and mentally count your fingers, refocus on your breathing switch to monitoring your tinnitus noises, then refocus on your breathing again. Notice how you are able to control your attention.

Some people find that building their tinnitus into a non-stressful mental image can help to reduce the distress it causes. For example, if your tinnitus sounds like waves crashing, take some time each day to shut your eyes and picture a beach. If the tinnitus sounds like whistling, try to picture a kettle boiling.

Tinnitus works a bit like an ‘emotional barometer’ – it is often more intrusive when there is stress or worry around. When you notice that the tinnitus is demanding your attention, ask yourself if there is anything else that is on your mind that you need to sort out. Having tinnitus does not make you immune to other worries and stresses – are you giving the tinnitus more credit for your stress than it deserves?

Worries are often made worse by avoiding the thing we are worried about. For example, if you avoid activities because you are worried they may make your tinnitus worse, then you won’t discover, as most people do, that the tinnitus settles down afterwards. This means that you will remain worried about the tinnitus and you will feel unhappy because you are not doing what you want to do. So live your life in spite of the tinnitus, not because of it. Do things because you want to rather than because you think they will help to ward-off the tinnitus. By planning your life around the tinnitus, you are feeding it with attention, and it will only demand more and more.

Advise those close to you of your quest to reduce the amount of attention your tinnitus receives. Explain why you are doing this and ask for support – perhaps suggest that they don’t ask you quite so often how your tinnitus is. Maybe they could help you to focus onother things.

DO NOT

• Feed the tinnitus by putting your life on hold while you chase a ‘cure’. There is no proven cure for tinnitus at this time – when there is, you’ll be sure to know about it! Remember, though, this does not mean you have to be controlled by tinnitus

• ‘Test’ your tinnitus – e.g. listening out for whether you can hear the tinnitus over the TV or trying to figure out whether the noises you are concentrating on are the tinnitus or your masker. Each time you are ‘listening out’ for the tinnitus you are guiding your attention towards it.

Getting a decent night’s sleep

Many people with tinnitus believe that the noises disrupt their sleep. If you have difficulty getting off to sleep it may be that the shift from a relatively noisy daytime environment to the quietness of the bedroom makes the tinnitus noises more noticeable – in the same way that a candle looks brightest in a dark room.

Some people find that having some low-level sound in the bedroom (e.g. wave sounds, a fan or calming music) can help to mask the tinnitus noises. However, using sound that is too loud or attention-grabbing (e.g. rock music or listening to a talk programme on the radio) may get in the way of falling asleep. It is also important to remember some general principles for promoting good sleep:

Do

• Try to reduce your daily caffeine intake and to cut caffeine out completely in the evening.

• Aim to get some exercise each day – but not too close to bedtime.

• Make time to move your head out of planning or worrying mode – before bedtime, spend a maximum of 10 minutes writing down ideas or issues you want to tackle tomorrow (but be realistic!)

• Make a point of winding down at least half an hour before going to bed (e.g. doing relaxation exercises, listening to soothing music).

• Try to get your brain used to thinking that bed = sleep by turning out the lights as soon as you get into bed.

• Try to restrict your alcohol intake. Alcohol can disrupt the natural sleep cycle.

• Try whispering a nonsense-word (e.g. ‘dah’) over and over – this may help to block out intrusive thoughts or worries.

• If you don’t get to sleep within 20 minutes of turning the lights out, OR you are awake for more than 20 minutes in the night, DON’T PANIC - get up, move to another room, and do something relaxing, not something that is going to grab your attention, or stimulate your brain, but something soothing and repetitive until you begin to feel more tired. Then go back to bed.

DO NOT

• Cat-nap in the daytime.

• Do anything mentally stimulating in your winding-down period before bed or when you go to bed, e.g. watching TV, doing crosswords or listening to talk programmes on the radio.

• Panic if you wake up. Your body will ensure you get the minimum sleep you need, but you can help it along by staying calm and relaxed.

• Some people believe that their tinnitus wakes them up during the night. This, however, is unlikely to be the case. Sleep naturally goes in cycles broken up by brief periods of waking (although we often don’t remember being awake). When people feel that their tinnitus has woken them up, it is more likely that they have tuned into the tinnitus noises during one of their natural waking periods.

Short term effects of stress Long term effects of stress

Wide eyes Nerves/sleeping badly

Edgyness Headache

Pale face Neck ache

Flared nostrils Hair stands on end

Dry mouth Shoulder ache

Hair stands on end Backache

Faster breathing

High blood pressure

Tense muscles

Loss of appetite

Sweaty hands

Leg ache

More sensitiveto touch

Poor circulation

Need to pass water

Less sensitiveto pain

Butterflies

Indigestion/ulcers

Faster heart beatHeart disease

StressRelax

muscles

Slowbreathing

Quieterthoughts

Controlbegins

Feelingof

calmness

ConfidentI cancope

Feelingsure ofmyselfSleep

problems

Cantcope

Irritable/angry

Physicaltirednesstension

Achesand

pains

Increase intinnitus

Decrease intinnitus

The spiral of tinnitus

The spiral of tinnitus

StressRelax

muscles

Slowbreathing

Quieterthoughts

Controlbegins

Feelingof

calmness

ConfidentI cancope

Feelingsure ofmyselfSleep

problems

Cantcope

Irritable/angry

Physicaltirednesstension

Achesand

pains

Increase intinnitus

Decrease intinnitus

Breathing excersises

The breathing exercises are about balance and control, there are many breathing exercises and they can greatly aid concentration, clarity of thought and produce a sense of inner quiet. We know that slowing the breath down can calm the mind and reduce tension. The exercises will take only about 5 minutes but you should feel no strain. If you become light headed stop them for the moment and try again later.

A suggested routine

Make sure that your back is straight and the shoulders relaxed. All breathing is through the nose, unless otherwise stated.

1 Take one or two easy breaths in and out, just watching it enter the body and leave the body. Observe the gentle rhythm that comes with breathing easily and effortlessly. This can be practised as many times as you like during the day and can, of course, be done anywhere.

2 Now extend the control by taking a COMPLETE breath IN for a count of 3 and then letting it OUT for the same count of 3. Fill the lungs completely so that the IN breath takes the same time as the OUT breath (the number does not matter – it is the balance that is important)

3 Further extend this exercise by breathing in for your count, and then breathing out for DOUBLE that count.

4 Take a breath in and out and then just stay quietly WITHOUT BREATHING IN AGAIN, for a little while, just until you feel the need to breathe in again. Let no strain enter in to the exercise. Notice the space between one breath and the next.

5 Take a breath in through the nose and then out through the nose and when you think the lungs are empty. BLOW OUT through the MOUTH, pursing the lips. It is surprising what air still remains.

6 The single nostril breathing: this requires two complete breaths. Start by closing the left nostril with your finger and breath up the right nostril. When you have breathed in completely, close the right nostril with the finger, and breathe OUT though the left nostril. Breathe UP the left nostril, then close this and breathe OUT though the right nostril. Repeat twice more without stopping if you wish

Contacts

Audiology Department DPOWTel 03033 304645

Audiology Department SGHTel 03033 302436

British Tinnitus Association (BTA)Tel 0800 018 0527 freephone

www.tinnitus.org.uk

www.takeontinnitus.org.uk learning programme

Action on Hearing Loss ( formerly RNID)Tel 0808 808 0123 freephonewww.actiononhearingloss.org.uk

HUSH self- help group (Hull)www.tinnitusexplained.org

Open Minds – For patients in North East Lincolnshire7-9 Osbourne Street, Grimsby, DN31 1EYTel 01472 625100 Email NAV.openminds@nhs.net

Mind – for patients in North LincolnshirePrinters Yard, Fenton Street, Scunthorpe, DN15 6QXTel 01724 279500 Email info@sdmind.org.ukwww.mind.org.uk

Steps2change – for patients in LincolnshireSPA Contact Centre, Sycamore Unit, Beacon Lane, Grantham, NG31 9DFTel 0303 123 4000Email lincs.spa@nhs.netwww.lpft.nhs.uk/steps2change-lincs

Listen Up - a local support group for those with Hearing difficultieswww.facebook.com/listenuplincolnshireEmail listenuplincolnshire@gmail.com

For Smart phones and Android phones “apps” are available to download. Including sounds of nature, seashore, and guided relaxations

Date of issue: Jan 20Review date: Jan 23Author: Helen Pick

IFP: 1103