CBT for Tinnitus: A Critical Tool

Written by:

Dr. Hamid Djalilian

Neurotology

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Does CBT for tinnitus work?

Cognitive Behavioral Therapy (CBT) for tinnitus works by changing thought patterns about intrusive ringing and introducing behavior therapies to reduce tinnitus distress.

In this article, I cover the following topics on CBT for tinnitus:

Introduction to CBT for Tinnitus

In treating people with tinnitus, there is too much attention on the ear and not enough on the brain. While it’s true that ear ringing starts with damage to the inner ear, it’s neural network changes in the brain that amplify and perpetuate tinnitus. The psychological aspects of tinnitus are just as important as the audiological ones.

Cognitive Behavioral Therapy (CBT) for tinnitus is a structured therapeutic approach designed to help individuals reframe and reshape their thoughts, feelings, and behaviors. CBT recognizes the interconnected nature of psychological well-being and the loudness of ear ringing.

In treating tinnitus, we must address the importance that negative thoughts have on amplifying tinnitus distress. CBT for tinnitus accomplishes this. Here are 3 key components of CBT as a tinnitus treatment:

What is cognitive therapy for tinnitus?

Cognitive therapy begins by identifying and challenging negative thought patterns related to chronic ear ringing. Tinnitus patients learn to replace distorted thought patterns with more balanced perspectives. This helps with anxiety, depression, and tinnitus distress.

What is behavioral therapy for tinnitus?

Behavioral therapies for tinnitus look at actions and reactions surrounding loud ringing. Behavioral treatments help people modify their reactions and develop coping strategies to better navigate how to live with chronic tinnitus.

What is psychoeducation for tinnitus?

Psychoeducation in CBT for tinnitus informs individuals about their condition, symptoms, and the therapy model, empowering them to understand the link between thoughts, emotions, and behaviors. Knowledge is power when it comes to tinnitus rehabilitation.

"I learned more about my tinnitus in the intro call than from my doctor..."

– Alice Lee

Female tinnitus patient Alice Lee

Ready for relief? NeuroMed can help.

The CBT Process in Tinnitus Management

Here’s a quick overview of how typical CBT for tinnitus program works.

CBT StepDescription
AssessmentCBT starts with identifying triggers, emotional responses, and behavioral patterns.
Goal SettingRealistic goals are set, ensuring that the CBT approach aligns with your specific needs in managing tinnitus-related distress.
InterventionCBT interventions are implemented, combining cognitive and behavioral strategies to reshape negative thoughts and modify responses to distress from tinnitus.
Skill DevelopmentPeople gain practical skills to improve coping with chronic tinnitus. This includes relaxation techniques, stress reduction methods, and more.
Progress MonitoringCBT involves continuous assessment to monitor progress, making necessary adjustments to the treatment plan as needed.
Process steps in CBT for Tinnitus.

At NeuroMed, we streamlined this process and converted it into an online program. Multiple studies have shown that app-based CBT is equally effective with in-person CBT. Clinical trials conducted at my academic clinic validated our app-based CBT program specifically designed for tinnitus patients.

What specific techniques are used in CBT for tinnitus?

Cognitive behavioral treatments often include the following techniques:

CBT TechniqueDescription
Imagery TechniquesUsing vivid mental images to explore and reframe thoughts, emotions, and behaviors that are having a negative impact on quality of life.
MindfulnessCultivating awareness and non-judgmental acceptance of the present moment, facilitating a deeper understanding of thoughts, emotions, and behaviors.
Cognitive RestructuringIdentifying and challenging irrational or unhelpful thoughts to promote healthier thinking patterns. This entails developing cognitive skills to address loud ringing and problems that come up in everyday life.
Behavioral ActivationEncouraging pleasurable activities to counteract depression and increase positive reinforcement. This helps chronic tinnitus patients endorse positive thoughts and combat negative emotions.
Relaxation TrainingInvolves various techniques, such as deep breathing and progressive muscle relaxation, to reduce physical tension and alleviate negative thoughts.
Acceptance and Commitment TherapyAccepting one’s thoughts and feelings while committing to actions aligned with personal values, promoting psychological flexibility and resilience.
CBT for tinnitus – selected techniques.

What are the common cognitive distortions with tinnitus?

CBT for tinnitus addresses cognitive distortions

Identifying negative thought patterns is one of the most fundamental exercises in CBT. Cognitive behavioral therapy refers to these negative thought patterns as “cognitive distortions”. Here are some of the most commonly recognized patterns that are highlighted in a typical CBT session:

Cognitive DistortionDescription
CatastrophizingBelieving that loud ringing is a sign of a serious or life-threatening condition, leading to excessive worry and fear.
RuminationContinuously focusing on the ringing sound and its perceived implications, which can intensify distress and anxiety.
OvergeneralizationExtending negative beliefs about tinnitus to other areas of life, such as believing it will ruin relationships or career prospects.
PersonalizationBlaming oneself for the development or persistence of loud ringing, leading to feelings of guilt or inadequacy.
All-or-Nothing ThinkingViewing intrusive tinnitus as an insurmountable problem without considering potential coping strategies or solutions.
Mind Reading Assuming others perceive tinnitus negatively or judge the individual because of it, leading to social withdrawal or avoidance.
Emotional ReasoningBelieving that the emotional distress caused by intrusive ringing reflects its severity or permanence, rather than recognizing emotions as subjective reactions.
FilteringIgnoring positive aspects of life or personal achievements due to preoccupation with tinnitus-related distress.
Catastrophic Future PredictionsAnticipating that ringing will worsen over time or significantly impair quality of life, leading to hopelessness and despair.
Overemphasis on ControlFeeling powerless or defeated because of the inability to control or eliminate tinnitus, overlooking the potential for adaptation and coping strategies.
These are the common cognitive distortions that are challenged in CBT for tinnitus.

CBT and Tinnitus Retraining Therapy (TRT)

What’s the difference between CBT and Tinnitus Retraining Therapy (TRT)? Both approaches recognize the importance of addressing the emotional and psychological aspects of tinnitus distress. Here are some important differences:

Practice ParameterCBTTRT
Habituation TherapyInvolves repeated exposure to a stimulus, leading to a decrease in response over time. Used for phobias and anxiety disorders.Refers to detaching attention from the tinnitus sound. It requires “mixing point masking”, where sound therapy files are set just above the tinnitus sounds.
PractitionerUsually performed by a licensed psychologist or through online programs.Performed by an audiologist who teaches you the “neurophysiological model” of tinnitus.
Use of Sound TherapyUsually includes education on sound treatment, but not a formal program.Relies heavily on an external source of sound to promote tinnitus habituation (i.e. sound therapy).
The differences between CBT for tinnitus and Tinnitus Retraining Therapy.

There has been only one clinical trial that I’m aware of that compared CBT with TRT in tinnitus patients. In this trail, CBT treatment performed significantly better than TRT (54.5% improvement at 6 months with CBT vs. 20% improvement for TRT) [3].

Rewiring Neural Networks with Tinnitus CBT

CBT for tinnitus changes neural networks

Beyond immediate symptom relief, CBT offers the potential for long-lasting benefits by rewiring the brain connections (neuroplasticity). In tinnitus, neural networks are established between multiple different functional areas of the brain. These brain regions are represented in the table below:

Brain RegionNeurophysiological Function
Auditory CortexProcesses sound signals received from the ears, including tinnitus perception.
Limbic SystemInvolved in emotions and memory, influencing the emotional response to tinnitus. The amygdala is part of the limbic system.
ThalamusActs as a relay station for sensory information, including auditory signals related to tinnitus.
Frontal CortexAssociated with attentional processes, impacting the perception and reaction to tinnitus. Includes the prefrontal cortex, were we have executive function.
Insular CortexIntegrates sensory information and regulates emotions, influencing tinnitus-related distress.
HippocampusInvolved in memory formation and retrieval, affecting the association between tinnitus and past experiences.
AmygdalaProcesses emotions, including fear and anxiety, contributing to the emotional response to tinnitus. It’s the “fight or flight” center.
Basal GangliaRegulates motor functions and may influence tinnitus perception through connections with the auditory system.
BrainstemIncludes structures like the cochlear nucleus and superior olivary complex, which are involved in auditory processing and may contribute to tinnitus perception.
Multiple brain regions are involved with tinnitus, not just the auditory system.

CBT promotes reorganization of the brain connections that drive tinnitus distress. This reduces the brain’s sensitivity to tinnitus signals and promotes lasting relief from tinnitus. Overall, treating tinnitus with CBT is an essential part of a comprehensive tinnitus rehabilitation program.

Is CBT for tinnitus effective?

Clinical trials consistently prove the efficacy of CBT as a tinnitus intervention. Several systematic reviews in the medical literature attest to the effectiveness of CBT for tinnitus, revealing significant improvements in health related quality of life and reductions in levels of anxiety, depression, and tinnitus distress [1].

As noted above, CBT treats tinnitus effectively because it addresses the neural networks that are established in chronic tinnitus. These neuroplastic changes are critical for providing a lasting solution to tinnitus distress.

Can mindfulness meditation help tinnitus?

Mindfulness meditation for tinnitus is a particularly well-studied CBT intervention for tinnitus and there is strong evidence of its effectiveness. In a recent meta analysis, the review authors report that mindfulness-based therapy showed a significant reduction in tinnitus distress scores in 6/7 trials that were studied [2]. Note that the overall quality of these studies were high and included randomized clinical trials.

Here are the most common mindfulness-based interventions for tinnitus:

Mindfulness TechniqueTechnique Description for Tinnitus Patients
Mindful BreathingFocusing on the sensations of breath entering and leaving the body to cultivate present-moment awareness and relaxation, reducing tinnitus-related stress.
Progressive RelaxationSystematically directing attention to different parts of the body, noticing sensations without judgment, promoting relaxation and detachment from tinnitus.
Mindful ListeningPaying attention to external sounds or internal tinnitus sounds without reacting emotionally, fostering acceptance and reducing distress associated with tinnitus.
Mindful MovementEngaging in gentle, intentional movements such as walking or yoga, connecting body and mind, and fostering a sense of groundedness and relaxation amidst tinnitus sensations.
Techniques of mindfulness meditation for tinnitus.

Mindfulness meditation is a powerful tool for those interested in natural remedies for tinnitus.

CBT for Tinnitus at NeuroMed

CBT for tinnitus App

At Neuromed, we fully embrace CBT as a core treatment for tinnitus. Clinical trials at my academic clinic were able to show that when sound therapy is added to CBT exercises, there is a much greater effect on reducing tinnitus.

App-Based CBT to Treat Tinnitus

First, several clinical studies have demonstrated that app-based CBT shows similar efficacy to in-person CBT [4]. Next, through clinical trials conducted at our university, we were able to achieve substantial improvements in tinnitus handicap scores (higher than many applications, including the Lenire device) [5]. At NeuroMed, this app-based CBT utilizes the Xtinnitus.com platform, which is based on the same protocol used in our clinical trials.

CBT Tinnitus Care by Telehealth

Using telemedicine technology in tinnitus management allows for greater flexibility and decreased time demand for tinnitus patients. Per above, we integrate internet-based CBT exercises into our program. Further, because we also use sound therapy, our program is akin to online TRT programs. That is, we combine the power of sound therapy with the cognitive benefits of app-based CBT for tinnitus. This makes for a very efficient and effective treatment approach.

Finally, because of the frequency of telehealth visits, our tinnitus patients enjoy the benefits of personalized counseling as well. These sessions allow an opportunity to engage in cognitive therapy, behavioral therapy, commitment therapy, and other related techniques used in CBT and TRT.

Integrating CBT with Medical Treatments for Tinnitus

When CBT is added to our integrative medicine management approach, we’re finding success rates that approach 90%. Our program is amplified by the use of prescription medications, nutraceuticals, and lifestyle interventions that address the migraine-like process that drives tinnitus loudness. The results is a truly progressive tinnitus management program optimized for accelerated results.

Conclusion: CBT for Tinnitus Works!

CBT stands out as an effective treatment and important tool in tinnitus management. CBT provides practical strategies and coping skills to navigate the challenges associated with tinnitus. It also helps restructure the brain, so that relief is long-lasting. This leads to significant improvement in tinnitus symptoms and overall quality of life.

Using technology like web-based CBT at Neuromed demonstrates how tinnitus treatments are evolving, offering personalized relief with modern convenience. As we learn more about tinnitus, combining traditional therapy with technology gives hope for lasting relief.

CBT for Tinnitus References
  1. Landry EC, Sandoval XCR, Simeone CN, Tidball G, Lea J, Westerberg BD. Systematic Review and Network Meta-analysis of Cognitive and/or Behavioral Therapies (CBT) for Tinnitus. Otol Neurotol. 2020 Feb;41(2):153-166. doi: 10.1097/MAO.0000000000002472. PMID: 31743297.
  2. Rademaker MM, Stegeman I, Ho-Kang-You KE, Stokroos RJ, Smit AL. The Effect of Mindfulness-Based Interventions on Tinnitus Distress. A Systematic Review. Front Neurol. 2019 Nov 1;10:1135.
  3. Westin VZ, Schulin M, Hesser H, Karlsson M, Noe RZ, Olofsson U, Stalby M, Wisung G, Andersson G. Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment of tinnitus: a randomized controlled trial. Behav Res Ther. 2011 Nov;49(11):737-47.
  4. Esfandiari N, Mazaheri MA, Akbari-Zardkhaneh S, Sadeghi-Firoozabadi V, Cheraghi M. Internet-Delivered Versus Face-to-Face Cognitive Behavior Therapy for Anxiety Disorders: Systematic Review and Meta-Analysis. Int J Prev Med. 2021 Nov 15;12:153.
  5. Abouzari M, Goshtasbi K, Sarna B, Ghavami Y, Parker EM, Khosravi P, Mostaghni N, Jamshidi S, Saber T, Djalilian HR. Adapting Personal Therapies Using a Mobile Application for Tinnitus Rehabilitation: A Preliminary Study. Ann Otol Rhinol Laryngol. 2021 Jun;130(6):571-577.

Dr. Hamid Djalilian

Neurotology

Dr. Hamid Djalilian, a tinnitus specialist and distinguished figure in the areas of otolaryngology, neurosurgery, and biomedical engineering, is NeuroMed’s Chief Medical Advisor.

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