The aim of every tinnitus sufferer is to habituate to their tinnitus.
This means reaching a state of mind where you no longer have a negative emotional response to your tinnitus.
We habituate or adapt to various stimuli every day of our lives:
- the feel of our clothes on our bodies
- the unchanging things we see around us each day
- traffic noise....
We all know people who have moved to a home or workplace on a busy street. At first they find the traffic noise distracting, even distressing, but in time reach the point where they are rarely even aware of the noise that surrounds them. This is called habituation.
In general, the noises we are most able to ignore are predictable, repetitive sounds we perceive as nonthreatening, uninteresting and unimportant.
Progression towards Habituation
Progression towards habituation is not a case of going from one level to another and not having relapses or bad days. Tinnitus sufferers have days when they may be overtired or have underlying stress in their lives. Tinnitus will be more troublesome on those days. However, through learning to manage your tinnitus, the bad days will be fewer and further apart.
As you learn to manage your tinnitus and progress towards habituation, changes will take place in the areas of depression, anxiety, your ability to concentrate, shifting your focus from the tinnitus and insomnia. In the early stages the majority of people have trouble in several or all of these areas. As you move towards habituation, each area will gradually improve to the point where you are rarely troubled by your tinnitus and it does not interfere with normal activities. Although the tinnitus will still be present, you will not be emotionally disturbed by it, or overly aware of it.
Tinnitus Habituation, and the Therapeutic use of Sound in the Management of Tinnitus
Myriam Westcott, Dineen and Westcott Audiology
Habituation to tinnitus
Most people who develop persistent tinnitus will spontaneously habituate or adapt to their tinnitus over time, so that while the tinnitus may still be heard, attention is rarely given to it and emotional acceptance is achieved - the tinnitus is neither pleasant nor unpleasant. Habituation is a normal reaction to any persistent stimulus. For example, just after putting your clothes on in the morning they can be felt on the skin, but this sensation lasts only a very short time. During the day, you do not notice their touch, even though skin receptors continue to send signals to the brain about the sensation of your clothes against your skin.
As you move towards habituation, you will notice a gradual increase in the periods of time when you are not aware of your tinnitus, as well as a gradual reduction in any annoyance or distress it may have caused. Illness and stress can lead to moving backwards in this process. Sometimes people become stuck and are unable to habituate as fully to their tinnitus as they would like. An awareness and understanding of your individual pattern of coping with setbacks and trauma, as well as stress management, may be required for habituation to be achieved.
Most therapeutic approaches to tinnitus management, including Tinnitus Retraining Therapy (TRT), aim for tinnitus habituation to be achieved. TRT is based on the neurophysiological model of tinnitus, and is a treatment aimed at retraining the subconscious parts of the brain to ignore the tinnitus sound.
Research has shown that almost everyone develops temporary tinnitus, if put in an abnormally quiet environment (such as a sound proof booth) and instructed to pay attention to any sound they may hear. You are more likely to notice or listen to your tinnitus in a quiet room. This increased awareness may lead to an increase in active monitoring of the tinnitus. This, in turn, may lead to an escalating cycle of increased irritation and distress, which will, in turn, increase the awareness and the intrusiveness of your tinnitus.
According to the neurophysiological model of tinnitus and hyperacusis, when people with tinnitus remain in a quiet environment for some time, the gain (or volume) in the central auditory pathway increases, resulting in enhancement of the tinnitus sound.
Our senses react not to the absolute value of a stimulus, but to the difference between the stimulus (or tinnitus) and the background. The tinnitus will not stand out as sharply and will be less obvious when surrounded by another sound.
Sound enrichment involves adding sound to your environment. The aim is to surround the tinnitus sound with a neutral sound which is easily ignored. Sound enrichment is an important component of most approaches to tinnitus management, and is an integral part of Tinnitus Retraining Therapy (TRT). For those people who have intermittent awareness of their tinnitus, sound enrichment can be restricted to times when the tinnitus is particularly noticeable or irritating. For people who are constantly aware of their tinnitus, 24-hour sound enrichment is recommended. This involves making sure there is always some sound present. By actively seeking to assert some control over the situation, the feelings of helplessness so often reported by people with tinnitus can be reduced.
You do not have to actively listen to the sound you choose. In fact, particularly when you do not wish to be stimulated by the sound, it is best to adopt a passive approach to the sound by ignoring it. I like to describe the sound as "acoustic wallpaper".
If you wish to listen to TV, radio and music, you will be distracted from your tinnitus, as well as less likely to be able to hear it. As a result it will become less prominent. However, most people don't want to be stimulated by these sounds for more than a few hours, let alone for 24 hours, and it is then appropriate to use less stimulating and blander sounds. The important thing is to have available a variety of sounds to suit your mood and the degree of stimulation you want.
There are many common sounds in our environment that are familiar, soothing, have pleasant associations or are at least neutral, and are fairly monotonous. For example, many people with tinnitus will not hear their tinnitus if walking on the beach, or in a park with the sound of birds and wind in the trees. This concept can be extended using an environmental sound generator, which typically produces a range of sounds such as ocean surf, bubbling river sounds etc. They can run on batteries as well as on mains electricity and are relatively portable. Alternatively, tapes/CDs of environmental sounds are available, some of which have gentle music incorporated.
Some people find FM radio static (the hissing sound heard when the radio is tuned between stations) an inexpensive, accessible neutral sound. A Walkman style portable cassette/CD player/radio with lightweight headphones can be a relatively inexpensive sound system that you can carry around with you. If you have hearing aids, it is advisable to use them for most of the day to enhance your awareness of these environmental sounds.
The sounds used should never cause annoyance or be unpleasant in any way. Because these sounds are neutral and relatively bland, they are easy to ignore. As a result, most people readily habituate to them.
Masking - how is it different to sound enrichment?
According to TRT, there is an ideal volume level when using a stable sound source such as a sound generator or CD. The volume should be set so that it starts to "mix" or blend with the tinnitus, and so that you can hear both your tinnitus as well as the sound used. To assist habituation to your tinnitus you need to be able to hear it along with the sound chosen. For this reason it is advisable not to swamp or "mask" your tinnitus for prolonged periods of time.
The discovery that tinnitus could be masked or blocked out by external sounds has been credited to the ancient Greeks over 2000 years ago. Tinnitus masking is not regarded as a form of treatment for tinnitus, but can provide relief in the short term by substituting a more pleasant sound for the tinnitus.
Sound enrichment during sleep
Constant low level neutral sound in the bedroom is recommended if your sleep is disturbed by your tinnitus. The tinnitus will not be as obvious when surrounded by another sound, whether you are trying to fall asleep or if you wake during the night. We have 3 or 4 periods of light sleep during the night, and some researchers claim that we are then able to hear our tinnitus. If your tinnitus causes you irritation or distress, hearing it could wake you up during those periods of light sleep. This is less likely to occur in the presence of other sound
When trying to fall asleep, don't focus on the low-level sound but let it move into the background of your awareness. To stop you focussing on your tinnitus, use gentle distraction strategies that do not involve sound, such as reading. Active relaxation exercises during the day can be useful in helping you to sleep more deeply. These can include progressive muscle relaxation exercises, breathing exercises and positive visualisation, all of which are available on tape/CD. Open Leaves Bookshop (79 Cardigan St., Carlton tel: 9347 2355) carries a range of books on stress management, as well as tapes/CDs. Yoga, meditation, tai chi classes can be of benefit as they incorporate or are based on active relaxation strategies.
Customised sound generators
For people with high levels of tinnitus related distress, who wish to follow a TRT approach to tinnitus management and have normal hearing, the fitting of customised, wearable sound generators is recommended in both ears. These look like hearing aids, fit either inside or behind the ears and provide low-level white noise, which sounds like a gentle hissing. They have an adjustable volume control, so that the recommended volume level can be set.
The advantage of customised sound generators is that they are discrete, portable, and provide a well-controlled, stable sound source. Because the sound they provide is constant, neutral, bland, and doesn't change in volume, you will find that it is easily ignored. Customised sound generators allow the ear canal to remain open, resulting in minimal interference with the ability to hear external sounds. Environmental sound enrichment can be used in addition to the customised sound generators.
Once an acceptable level of habituation to your tinnitus is reached, the use of the sound generators can be discontinued.
Tinnitus and hearing loss - Hearing Aids
People with a hearing loss often blame their tinnitus for their hearing problems, particularly when communicating in groups and in background noise. The tinnitus is a symptom of the hearing loss, not the cause. If you have a hearing loss, then hearing aids will be effective in both the management of your hearing loss and your tinnitus.
Hearing aids, by amplifying external sounds around you, will result in your internal noise, or tinnitus, becoming less noticeable. To be effective in managing both the hearing loss and the tinnitus, hearing aids need to be worn for most of the day.
The effort of straining to hear a conversation and the resultant communication difficulties frequently lead to frustration, fatigue and stress. These are all major aggravating factors in tinnitus awareness and annoyance. Once you have adapted to the amplification provided by your hearing aids, you can expect a significant reduction in stress and fatigue.
Because your hearing loss is likely to have developed over some time, your concept of what is "normal " hearing has also slowly changed. When hearing aids are fitted for the first time, and sounds are boosted to the level they should be heard, your concept of what is "normal" hearing will need to be adjusted. Many sounds will seem unnaturally prominent or noticeable for the first few weeks, as it takes time for the brain to relearn these sounds. This adaptation or adjustment period may last up to several months. For this process of adaptation to occur, it is advisable to use your hearing aids for most of the day.
Your hearing aid may be less effective as a tinnitus management tool when you are in a quiet environment. Sound enrichment is required, using the strategies previously outlined. It is important to remember, however, that most people with a hearing loss will have a reduced ability to hear a voice through background noise. Digital signal processing hearing aids are now available with multiple channels, twin microphones and noise suppression features to assist communication in background noise. Conventional hearing aids do not have these features.
When you remove your hearing aids, you may notice your tinnitus appears more prominent. Don't be concerned about this; it is simply due to the lack of amplification of environmental sounds making your tinnitus seem louder by contrast. Try not to remove your hearing aids in a quiet environment; increasing the volume of environmental sound will help.
A combination hearing aid and sound generator is now available in one high quality digital signal processing device, allowing the wearer to switch between the two functions as needed. When in quiet you use the sound generator function; when there are environmental sounds or conversation to listen to, you use the hearing aid function. If you are using your sound generator function, you may miss hearing a voice speaking to you. Knowing that your attention will need to be gained prior to a speaker launching into conversation with you should overcome any communication issues that may arise.
Further down the track, if you no longer need the sound generator function on the hearing aid, it can be reset to provide you with a second listening program for use in a noisy environment.