Understanding Stress and Tinnitus

There's a strong two-way association between tinnitus and stress. Understanding this connection is critical for those who suffer from tinnitus. Here, I'll review the following topics:

• The Vicious Cycle of Tinnitus and Stress
• Anxiety Disorders, Stress, and Tinnitus Defined
• Can stress cause ringing in the ears?
• How Stress Affects the Brain
• Can tinnitus cause anxiety and stress?
• How to Overcome Anxiety, Tinnitus, and Stress

The Vicious Cycle of Tinnitus and Stress

While stress doesn't directly cause tinnitus, it plays a pivotal role in amplifying its loudness and annoyance. When ear ringing is secondary to stress, it's called “stress-induced tinnitus”. That is, the stress is initiates and amplifies the tinnitus sound.

Here's a striking comment in a recent medical paper on tinnitus; “Psycho-social stress has been shown to share the same probability of developing tinnitus as occupational noise”[1]. That is, stress and “listening to a jackhammer” have the same probability of causing tinnitus!

At the same time, persistent tinnitus can be disturbing to the point where it acts to amplify stress (i.e. tinnitus caused the stress). When people get anxiety secondary to tinnitus, an inflammatory response can occur in the brain (much like a migraine). This inflammation then amplifies the existing tinnitus sound even louder. 

The bottom line is that there's a vicious cycle where stress and tinnitus amplify each other.

Anxiety Disorders, Stress, and Tinnitus

Before we begin, let’s establish some working definitions of anxiety, stress, and tinnitus. 

Anxiety Definition

Anxiety is defined as a response to perceived threats, characterized by apprehension, worry, and fear, and often accompanied by physical symptoms. Anxiety disorders, including generalized anxiety disorder, social anxiety disorder, panic disorder, and specific phobias, involve persistent and excessive anxiety symptoms that may significantly impact daily functioning. 

What is trait anxiety?

Trait anxiety refers to an individual's predisposition or baseline level of anxiety in response to various stressors. It represents a stable characteristic and is often measured as a personality trait, indicating how likely an individual is to experience anxiety across different situations. People with trait anxiety may never feel the need to seek psychiatric medical care. 

Stress Definition

Stress is medically defined as a physiological and psychological response to challenging or threatening situations. Importantly, stress can either be a psychological symptom or secondary to trauma, infection, or other forms of bodily stress. The body's adaptive reaction involves the activation of the “fight or flight” response, releasing stress hormones such as cortisol and adrenaline. Chronic or excessive stress can have negative effects on physical and mental health.

What is Tinnitus?

Tinnitus refers to hearing a sound in the absence of an external source. Tinnitus is a common condition where people hear a sound of ringing, buzzing, or hissing. While occasional ringing in one or both ears is normal, clinically significant tinnitus is persistent, intrusive, and oppressive. Part of what sets these tinnitus symptoms apart from mild tinnitus is the neural network connections between the auditory system and the fear center of the brain (the limbic system).

What is pulsatile tinnitus?

Pulsatile tinnitus refers to a type of tinnitus where you can hear the whooshing of your heart beating in your ears. A common cause is high blood pressure changes that accompany a psychological symptom like stress. If this is happening, you should consult with your doctor, as it may be a symptom of something correctable. For the rest of the article, we'll focus on subjective tinnitus (like high-pitched ringing).

Can stress cause ringing in ears?

Stress can amplify the loudness and annoyance of ear ringing, making the tinnitus worse. Stress can either be from psychological pressure or from bodily stress (i.e. trauma or infection). A person with stress-induced tinnitus may not yet have constant ear ringing. Rather, they only hear the ear ringing when they experience stress.

In people with existing tinnitus, stress can amplify the ear ringing sound, making the tinnitus worse than their typical baseline. Research shows that people experience louder and more bothersome tinnitus when they're feeling stressed [2]. Stress is a leading cause of tinnitus fluctuations.

How does stress affect the brain?

Physiological and emotional stress can cause dramatic changes in the way the brain functions. This can be particularly important in conditions that are sensitive to these changes, like migraine and tinnitus.

Stress can amplify tinnitus loudness through the following mechanisms:

Brain Impact of Stress	How It Amplifies Tinnitus
Increased Neural Activity	Stress hormones can enhance neural activity in the hearing pathways, making the perception of tinnitus more pronounced.
Neuroinflammation	Stress can increase inflammation in the brain. This can increase tinnitus loudness via the migraine pathway.
Blood Flow Changes	Stress can reduce blood flow to the inner ear, which can negatively impact the hair cells and other structures in the auditory system and worsen tinnitus symptoms.
Central Auditory Processing	Stress can directly affect central auditory processing, meaning that it changes how the nervous system responds to hearing nerve signals, increasing the awareness of and sensitivity to hearing tinnitus sounds.
Emotional Amplification	Stress heightens emotional responses. Heightened emotional states, such as anxiety or frustration, is a contributing factor to worsening tinnitus.
Impact on Sleep	Stress often disrupts sleep patterns and inadequate sleep can contribute to worsening tinnitus symptoms. Stress, sleep, and tinnitus are all interrelated.
Hearing Hypersensitivity	Stress-induced tinnitus can amplify environmental noise, making ordinary sounds loud or annoying (hyperacusis and misophonia).

Understanding these connections highlights the importance of managing stress. The key is to understand that stress is not just psychological, it has brain-side impacts and these can amplify your tinnitus.

• Timely treatment: In the beginning, stress-related tinnitus may be reversible, as the neural networks connecting the fear and hearing centers in the brain are not fully established. However, with time, these neural networks become harder to reverse and only respond to intensive exercises, like cognitive behavioral therapy.
• Meniere's Disease: We now know that stress is a significant risk factor for triggering Meniere's disease symptoms (vertigo, ear fullness, hearing loss, and tinnitus). Meniere’s disease is closely linked with ringing ears.

Can tinnitus cause anxiety and stress?

Tinnitus acts as a trigger for anxiety and stress, where the anxiety is secondary to tinnitus. That is, a constant loud ringing sound in the ears can induce a stress response. Here are the ways that tinnitus can cause anxiety and stress

Psychological Impact of Tinnitus	Description
Cognitive Focus	Constant awareness of tinnitus sounds can lead to a heightened cognitive focus on the auditory sensations. This persistent attention to the perceived ringing noise may contribute to increased stress levels.
Emotional Impact	Tinnitus can evoke emotional responses, including anxiety, frustration, or fear, particularly if the sounds are perceived as bothersome or disruptive. These emotional reactions can trigger the stress response in the brain.
Sleep Disturbances	Tinnitus may interfere with sleep, leading to inadequate rest. Sleep is crucial for stress regulation, and disruptions in sleep patterns can contribute to an elevated stress response.
Negative Impact on Quality of Life	For some individuals, tinnitus can negatively impact various aspects of daily life, including work, relationships, and social activities. The resulting decrease in overall quality of life may contribute to chronic stress.
Fear and Anticipation	The fear of tinnitus worsening or the anticipation of experiencing distressing sounds can create a constant state of alertness, further activating the stress response.
Neural Network Connections	Research suggests that there are neural network connections between the auditory cortex and the fear center of the brain. These connections can enhance the emotional significance of tinnitus, amplifying stress responses.
Catastrophizing	Individuals with tinnitus may engage in catastrophizing, where they excessively focus on the negative consequences of the condition. This “cognitive distortion” can contribute to heightened stress levels.

Tinnitus anxiety is harder to treat in the sense that the neural networks between the inner ear and the brain's fear center are already established. Treatment necessarily involves a process of rewiring the brain so that tinnitus perception becomes uncoupled from the stress response. 

How to Overcome Anxiety, Tinnitus, and Stress

Addressing the psychological impact of stress on tinnitus is essential in breaking the vicious cycle. Here are some treatment options that may help if you feel stressed:

Intervention	Description
Exercise for Stress Reduction	Regular physical activity serves as a powerful tool for stress reduction, releasing endorphins that counteract anxiety symptoms and promoting overall well-being. Incorporating exercise into daily routines can contribute to a balanced and calm state of mind.
Caffeine Reduction	Minimizing caffeine intake is another effective strategy for managing stress. Excessive caffeine consumption can contribute to heightened anxiety, and reducing intake can lead to a more balanced mental state, positively impacting stress-related tinnitus.
Mindfulness Practices	Mindfulness meditation is a valuable tools for staying present and calm. Cultivating a mindful awareness breaks the cycle of stress and tinnitus amplification, promoting a more harmonious experience.
Cognitive Behavioral Therapy (CBT)	CBT techniques address the negative thought patterns and behaviors that perpetuate stress. A recent review showed that across multiple clinical trials, CBT can helped people reduce tinnitus-related stress [3].
Sleep Optimization	Optimizing sleep is essential for stress management and overall well-being. Quality sleep contributes to a restful experience, alleviating the impact of stress on tinnitus symptoms.
Sound Therapy	One of the best ways to take the edge off of tinnitus in one or both ears is to use sound therapy. This suppresses the hyperactivity of the tinnitus and gives your brain a rest.
Medications	At NeuroMed, we frequently prescribe medications as part of the overall tinnitus treatment program. These doctor-prescribed medications can often help to reduce stress-induced tinnitus.
Deep Breathing	Diaphragmatic breathing reduces stress by activating the parasympathetic nervous system, creating a calming effect. This simple intervention is a powerful way to break the cycle of tinnitus and stress.

Stress, Tinnitus, and Migraine

While addressing stress is critical, it is only one of many factors that can trigger loud tinnitus through the migraine process. Stress, alongside other triggers such as sleep disturbances, dietary habits, hormonal fluctuations, jaw clenching, and environmental factors can activate the complex neurological pathways associated with migraine and tinnitus. These triggers contribute to heightened neural excitability and central sensitization, leading to louder and more distressing tinnitus episodes.

A comprehensive tinnitus management program must therefore go beyond stress reduction to address the broader spectrum of migraine-related triggers. This includes personalized approaches such as dietary adjustments to avoid common migraine triggers, pharmacologic treatments targeting neuroinflammation and neural hyperactivity, and sound therapy to stabilize auditory processing. By recognizing and addressing the multifactorial nature of tinnitus loudness, patients can achieve more effective and lasting relief.

Conclusion: Breaking the Tinnitus-Stress Cycle

The tinnitus-stress cycle can be addressed by integrating stress management strategies and seeking help from a doctor or other medical professional when appropriate. Identifying and addressing the underlying cause of your stress is critical in decreasing ringing ears.

At NeuroMed, we offer full-spectrum tinnitus care via telehealth. We use an integrative medicine approach to treatments, addressing all aspects of tinnitus in order to accomplish long-lasting tinnitus relief. Our program is perfectly suited for tinnitus sufferers who are battling with the vicious cycle of chronic stress and tinnitus.

References on Tinnitus and Stress

[1] Patil JD, Alrashid MA, Eltabbakh A, Fredericks S. The association between stress, emotional states, and tinnitus: a mini-review. Front Aging Neurosci. 2023 May 3;15:1131979.

[2] Elarbed A, Fackrell K, Baguley DM, Hoare DJ. Tinnitus and stress in adults: a scoping review. Int J Audiol. 2021 Mar;60(3):171-182.

[3] Hesser H, Weise C, Westin VZ, Andersson G. A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Clin Psychol Rev. 2011 Jun;31(4):545-53.