Cognitive Behavioral Therapy for Tinnitus
Cognitive Behavioral Therapy (CBT) for tinnitus is more than just a psychological approach—it has the potential to reshape the brain’s structure and chemistry. By helping individuals reframe their thoughts, feelings, and behaviors towards the ringing sound, CBT addresses the negative patterns that amplify tinnitus distress. This process fosters the creation of new neural pathways and can influence neurotransmitter levels in the brain. Supported by strong clinical evidence, CBT is a core strategy that can bring about lasting changes and tinnitus relief.
In this article, I cover the following topics on CBT for tinnitus:
- Introduction to CBT for Tinnitus
- The CBT Process in Tinnitus Management
- What are the common cognitive distortions associated with tinnitus?
- CBT vs. Tinnitus Retraining Therapy
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 and they have real consequences on brain structure and chemistry. This is where CBT for tinnitus comes in.
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 and calms the ‘fight or flight' center down.
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 to the tinnitus sound and develop coping strategies to better navigate how to live with chronic tinnitus. An example of a simple behavioral therapy intervention is deep breathing.
What is psychoeducation for tinnitus?
Psychoeducation informs individuals about their condition, symptoms, and the logic behind their treatment, empowering them to understand the link between thoughts, emotions, and behaviors. Knowledge is power when it comes to tinnitus rehabilitation.
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CBT and Tinnitus: How it Works
Here's a quick overview of how typical CBT for tinnitus program works.
| CBT Step | Description |
|---|---|
| Assessment | CBT starts with identifying triggers, emotional responses, and behavioral patterns. |
| Goal Setting | Realistic goals are set, ensuring that the CBT approach aligns with your specific needs in managing tinnitus-related distress. |
| Intervention | CBT interventions are implemented, combining cognitive and behavioral strategies to reshape negative thoughts and modify responses to distress from tinnitus. |
| Skill Development | People gain practical skills to improve coping with chronic tinnitus. This includes relaxation techniques, stress reduction methods, and more. |
| Progress Monitoring | CBT involves continuous assessment to monitor progress, making necessary adjustments to the treatment plan as needed. |
At NeuroMed, we streamlined this process and converted it into a self-directed online program. Multiple studies show that app-based CBT is equally effective with in-person CBT. Clinical trials conducted at my clinic proved that our tinnitus-specific CBT program is both effective and user friendly.
What specific techniques are used in CBT for tinnitus?
Cognitive behavioral treatments often include the following techniques:
| CBT Technique | Description |
|---|---|
| Imagery Techniques | Using vivid mental images to explore and reframe thoughts, emotions, and behaviors that are having a negative impact on quality of life. |
| Mindfulness | Cultivating awareness and non-judgmental acceptance of the present moment, facilitating a deeper understanding of thoughts, emotions, and behaviors. |
| Cognitive Restructuring | Identifying 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 Activation | Encouraging pleasurable activities to counteract depression and increase positive reinforcement. This helps chronic tinnitus patients endorse positive thoughts and combat negative emotions. |
| Relaxation Training | Involves various techniques, such as deep breathing and progressive muscle relaxation, to reduce physical tension and alleviate negative thoughts. |
| Acceptance and Commitment Therapy | Accepting one's thoughts and feelings while committing to actions aligned with personal values, promoting psychological flexibility and resilience. |
What are the common cognitive distortions with tinnitus?
Identifying negative thought patterns is one of the most fundamental goals of tinnitus 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 Distortion | Description |
|---|---|
| Catastrophizing | Believing that loud ringing is a sign of a serious or life-threatening condition, leading to excessive worry and fear. |
| Rumination | Continuously focusing on the ringing sound and its perceived implications, which can intensify distress and anxiety. |
| Overgeneralization | Extending negative beliefs about tinnitus to other areas of life, such as believing it will ruin relationships or career prospects. |
| Personalization | Blaming oneself for the development or persistence of loud ringing, leading to feelings of guilt or inadequacy. |
| All-or-Nothing Thinking | Viewing 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 Reasoning | Believing that the emotional distress caused by intrusive ringing reflects its severity or permanence, rather than recognizing emotions as subjective reactions. |
| Filtering | Ignoring positive aspects of life or personal achievements due to preoccupation with tinnitus-related distress. |
| Catastrophic Future Predictions | Anticipating that ringing will worsen over time or significantly impair quality of life, leading to hopelessness and despair. |
| Overemphasis on Control | Feeling powerless or defeated because of the inability to control or eliminate tinnitus, overlooking the potential for adaptation and coping strategies. |
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 Parameter | CBT | TRT |
|---|---|---|
| Habituation Therapy | Involves 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. |
| Practitioner | Usually performed by a licensed psychologist or through online programs. | Performed by an audiologist who teaches you the “neurophysiological model” of tinnitus. |
| Use of Sound Therapy | Usually 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). |
There has been only one clinical trial that I'm aware of that compared CBT with TRT in tinnitus patients. In this trail, a form of CBT called Acceptance and Commitment Therapy (ACT) performed significantly better than TRT (54.5% improvement vs. 20% improvement ) [3].
Rewiring Neural Networks with Tinnitus CBT
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 Region | Neurophysiological Function |
|---|---|
| Auditory Cortex | Processes sound signals received from the ears, including tinnitus perception. |
| Limbic System | Involved in emotions and memory, influencing the emotional response to tinnitus. The amygdala or “fear center” is part of the limbic system. |
| Thalamus | Acts as a relay station for sensory information, including auditory signals related to tinnitus. |
| Frontal Cortex | Associated with attentional processes, impacting the perception and reaction to tinnitus. Includes the prefrontal cortex, were we have executive function. |
| Insular Cortex | Integrates sensory information and regulates emotions, influencing tinnitus-related distress. |
| Hippocampus | Involved in memory formation and retrieval, affecting the association between tinnitus and past experiences. |
| Amygdala | Processes emotions, including fear and anxiety, contributing to the emotional response to tinnitus. It's the “fight or flight” center. |
| Basal Ganglia | Regulates motor functions and may influence tinnitus perception through connections with the auditory system. |
| Brainstem | Includes structures like the cochlear nucleus and superior olivary complex, which are involved in auditory processing and may contribute to tinnitus perception. |
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 Technique | Technique Description for Tinnitus Patients |
|---|---|
| Mindful Breathing | Focusing on the sensations of breath entering and leaving the body to cultivate present-moment awareness and relaxation, reducing tinnitus-related stress. |
| Progressive Relaxation | Systematically directing attention to different parts of the body, noticing sensations without judgment, promoting relaxation and detachment from tinnitus. |
| Mindful Listening | Paying attention to external sounds or internal tinnitus sounds without reacting emotionally, fostering acceptance and reducing distress associated with tinnitus. |
| Mindful Movement | Engaging in gentle, intentional movements such as walking or yoga, connecting body and mind, and fostering a sense of groundedness and relaxation amidst tinnitus sensations. |
Mindfulness meditation is a powerful tool for those interested in natural remedies for tinnitus.
CBT for Tinnitus at NeuroMed
At Neuromed, we fully embrace CBT as a core treatment for tinnitus. Clinical trials at my 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.
At NeuroMed, 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 of 85-90%. 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: FAQs
What is the best therapy for tinnitus?
The best therapy for tinnitus is Cognitive Behavioral Therapy (CBT), especially when combined with sound therapy and medical care. CBT helps reduce the emotional impact of tinnitus, making the sound feel less intrusive. It's clinically proven and often more effective than traditional masking treatments alone.
Does CBT help with tinnitus?
Yes, CBT is one of the most effective treatments for reducing tinnitus distress. It helps reframe negative thoughts and retrain how the brain responds to the ringing sound. Many patients experience lasting relief when CBT is used consistently as part of a structured treatment plan.
What is cognitive retraining therapy for tinnitus?
Cognitive retraining therapy for tinnitus involves changing unhelpful thought patterns that make tinnitus worse. It uses CBT principles to shift focus away from the sound and reduce emotional distress. Over time, it helps the brain form new habits and responses, easing the impact of tinnitus.
How does behavioral therapy help tinnitus?
Behavioral therapy helps tinnitus by teaching you how to manage reactions to the sound. It focuses on reducing avoidance, fear, and stress responses. Techniques like relaxation, exposure, and lifestyle changes improve coping and can reduce the brain's sensitivity to tinnitus over time.
Does CBT rewire your brain?
Yes, CBT helps rewire your brain by creating new neural pathways that reduce the emotional and attentional grip of tinnitus. It reshapes how your brain processes the sound, making it feel less threatening or loud. This neuroplastic change is key to long-term relief.
How do I train my brain to stop tinnitus?
You can train your brain to reduce tinnitus by using CBT techniques that rewire how your brain responds to sound. This includes mindfulness, cognitive restructuring, and emotional regulation strategies. With practice, the brain becomes less reactive to the ringing, helping it fade into the background.
CBT for Tinnitus References
- 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.
- 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.
- 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.
- 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.
- 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.
