For some people, tinnitus is a faint hum they notice now and then. For others, the ringing, buzzing or hissing becomes the loudest thing in their life: it is there when they wake, it gets worse when they are tired or stressed, and it makes silence impossible. If you live with tinnitus, you know how exhausting it can be, and how hard it is to explain to people who cannot hear it.
In this article I want to explain how the nervous system and the mind are involved in tinnitus, why the distress varies so much between people, and what research says helps.
What tinnitus is
Tinnitus means hearing a sound that has no external source. It is very common. A Cochrane review estimates that it affects up to 21% of adults, and that 1% to 3% experience severe problems with it (Fuller et al., 2020). Tinnitus is often linked with hearing loss, noise exposure or ageing, and sometimes with other conditions, so a medical examination by an ear, nose and throat specialist is an important first step.
The role of the brain and nervous system
Tinnitus usually begins in the hearing system, for example after damage to the inner ear. What happens next takes place largely in the brain. One influential model suggests that the brain normally has a kind of noise-cancelling system: areas involved in emotion and evaluation, the limbic system, help to filter out an unimportant tinnitus signal before it reaches awareness. When this filtering does not work well, the tinnitus becomes chronic and noticeable (Rauschecker et al., 2010).
This helps explain why tinnitus is so closely connected with stress and emotions. When we are anxious, tired or under pressure, the nervous system is on alert, and the brain gives more weight to signals that seem threatening. A ringing ear can then turn into a constant alarm.
Why the sound bothers some people more than others
Psychological research shows that the distress caused by tinnitus depends a lot on how we interpret and respond to it. A cognitive behavioural model of tinnitus describes how thoughts such as “This will never stop” or “I’ll go mad”, together with selective attention to the sound and behaviours like constant checking or avoiding silence, can increase distress and keep the brain focused on the tinnitus (McKenna et al., 2014).
This is good news in a way: while the sound itself may be hard to change, the way the brain and mind respond to it can change.
Good to know
Many people find that the loudness they hear does not match how much it bothers them. Two people with similar tinnitus can experience it very differently, depending on stress, sleep, mood and how they relate to the sound.
What research says helps
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is the best-studied psychological treatment for tinnitus. A Cochrane review of 28 studies with more than 2,700 participants found that CBT may reduce the impact of tinnitus on quality of life at the end of treatment compared with no intervention, by around 11 points on a common 100-point questionnaire, which is more than the minimal difference people notice. It may also slightly reduce depression (Fuller et al., 2020). The aim of CBT is to help people live with the sound with less distress, even if the sound itself remains.
CBT can also be delivered online. In a randomised trial, an internet-based guided self-help programme for chronic tinnitus was compared with group CBT and a discussion forum, and both CBT formats reduced tinnitus distress (Jasper et al., 2014).
Hearing care and sound
Hearing aids for people with hearing loss, and sound enrichment such as soft background sounds, can help the brain shift attention, and many people find them useful. A Cochrane review found that people using hearing aids or sound generators often improved, although the studies could not show that these devices work better than good information and advice alone (Sereda et al., 2018). Sound therapy seems to work best when it is adapted to the person (Searchfield et al., 2017). Your ENT specialist or audiologist can advise you.
Masking, exposure, or a mix of both
There is no single right answer to the question of whether you should cover the sound or let yourself hear it. Masking, which means covering the tinnitus with other sounds, can be a real relief at night, when you need to concentrate, or on days when everything feels too much.
At the same time, masking all the time can keep the tinnitus in the role of an enemy that must never be heard. The cognitive behavioural model of tinnitus describes how always avoiding silence can work as a safety behaviour that keeps attention on the sound and keeps the fear alive (McKenna et al., 2014). People who are more afraid of their tinnitus and more watchful of it tend to have a lower quality of life (Cima et al., 2011). Allowing the sound to be there, in quiet moments and without fighting it, works more like exposure: over time the brain can learn that the sound is unpleasant and not dangerous, and the alarm around it can calm down. People who accept their tinnitus more tend to feel less distressed by it (Riedl et al., 2015).
For many people, a mix works best: sound when it is truly needed, and some time in quieter places without covering the tinnitus completely. Tinnitus retraining therapy follows a similar idea and uses soft sound below the level that would cover the tinnitus, so that the brain can still get used to it (Jastreboff & Jastreboff, 2000). A good goal in therapy is to organise your life less and less around the tinnitus: fewer rules about where you can go, which rooms you avoid and which sounds you need, and more room for what matters to you.
Ways to cope in everyday life
- Use sound flexibly. Soft background sounds can help at night or when you need to concentrate. It also helps to spend some time in quieter places without covering the sound, so the brain can get used to it.
- Notice the stress link. When the tinnitus gets louder, check in with yourself: Am I tired? Tense? Worried? Caring for the stress often helps the tinnitus too.
- Calm the nervous system. Slow breathing, relaxation exercises and gentle movement can lower the body’s alarm level.
- Shift attention, gently. Fighting the sound keeps it in focus. Activities that absorb you, like conversation, music or hobbies, help the brain move it to the background.
- Protect your sleep. Regular sleep times and a calm routine before bed help, since tiredness makes tinnitus harder to bear.
- Question catastrophic thoughts. “This is unbearable” can become “This is unpleasant right now, and I have coped before.”
- Protect your ears from loud noise.
Tinnitus and sleep
Many people notice their tinnitus most at night, when the world is quiet. Worrying about not sleeping then adds to the problem. Some things help: a regular bedtime routine, soft background sound, avoiding screens in the last hour before bed, and getting up for a while if you cannot sleep, instead of lying awake and listening to the sound. Cognitive behavioural approaches for insomnia work well for many people and can be combined with tinnitus-focused therapy.
Talking about tinnitus with others
Tinnitus is invisible, and people around you may not understand how tiring it can be. Explaining it simply can help: you hear a sound others do not, it gets louder when you are stressed or tired, and very quiet or very loud rooms can be hard. You do not owe anyone a long explanation, but letting a few close people know makes it easier to ask for what you need, such as a table away from the speakers or a short break during a long evening. Self-help groups for tinnitus can also be a place where you feel understood quickly.
When to look for support
It can help to speak with a therapist if tinnitus is affecting your sleep, mood, work or relationships, if you feel anxious or hopeless about it, or if you notice that you are withdrawing from life. Psychological support is often part of specialised tinnitus treatment. You may also find Living with a chronic illness helpful.
Sudden hearing loss or sudden tinnitus in one ear should be checked by a doctor promptly. If you feel desperate or have thoughts of ending your life, please call your local emergency number (for example 112 in Europe or 911 in North America and Mexico), or find a free, confidential helpline in your country at findahelpline.com.
More about therapy with me.
References
- Cima, R. F., Crombez, G., & Vlaeyen, J. W. (2011). Catastrophizing and fear of tinnitus predict quality of life in patients with chronic tinnitus. Ear and Hearing, 32(5), 634–641. https://doi.org/10.1097/aud.0b013e31821106dd
- Fuller, T., Cima, R., Langguth, B., Mazurek, B., Vlaeyen, J. W., & Hoare, D. J. (2020). Cognitive behavioural therapy for tinnitus. The Cochrane Database of Systematic Reviews, 1, CD012614. https://doi.org/10.1002/14651858.cd012614.pub2
- Jasper, K., Weise, C., Conrad, I., Andersson, G., Hiller, W., & Kleinstäuber, M. (2014). Internet-based guided self-help versus group cognitive behavioral therapy for chronic tinnitus: A randomized controlled trial. Psychotherapy and Psychosomatics, 83(4), 234–246. https://doi.org/10.1159/000360705
- Jastreboff, P. J., & Jastreboff, M. M. (2000). Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Journal of the American Academy of Audiology, 11(3), 162–177. https://doi.org/10.1055/s-0042-1748042
- McKenna, L., Handscomb, L., Hoare, D. J., & Hall, D. A. (2014). A scientific cognitive-behavioral model of tinnitus: Novel conceptualizations of tinnitus distress. Frontiers in Neurology, 5, 196. https://doi.org/10.3389/fneur.2014.00196
- Rauschecker, J. P., Leaver, A. M., & Mühlau, M. (2010). Tuning out the noise: Limbic-auditory interactions in tinnitus. Neuron, 66(6), 819–826. https://doi.org/10.1016/j.neuron.2010.04.032
- Riedl, D., Rumpold, G., Schmidt, A., Zorowka, P. G., Bliem, H. R., & Moschen, R. (2015). The influence of tinnitus acceptance on the quality of life and psychological distress in patients with chronic tinnitus. Noise & Health, 17(78), 374–381. https://doi.org/10.4103/1463-1741.165068
- Searchfield, G. D., Durai, M., & Linford, T. (2017). A state-of-the-art review: Personalization of tinnitus sound therapy. Frontiers in Psychology, 8, 1599. https://doi.org/10.3389/fpsyg.2017.01599
- Sereda, M., Xia, J., El Refaie, A., Hall, D. A., & Hoare, D. J. (2018). Sound therapy (using amplification devices and/or sound generators) for tinnitus. The Cochrane Database of Systematic Reviews, 12, CD013094. https://doi.org/10.1002/14651858.cd013094.pub2
This article is exploratory and meant for information and reflection. It cannot capture the full complexity of any individual situation, and your own experience may be different. It does not replace a diagnosis or treatment.
