The role of stress, fear, and anxiety in tinnitus bother

Just about everyone with tinnitus agrees that ‘stress increases tinnitus bother while relaxation decreases tinnitus bother’. In each person’s search for a set of management tools to work with tinnitus, it is helpful to assess whether the chosen tool also decrease stress. As an example, while an anti-anxiety medication is not an FDA approved drug for tinnitus, it can get at the root of anxiety. By lessening anxiety, you are reducing stress and therefore, tinnitus may not be perceived as being so bothersome. The same goes for an anti-depressant.

Being depressed and/or anxious is very stressful on the mind and body. By taking an anti-depressant or anti-anxiety medication (whether short term or long term) the stress caused by being anxious or depressed is often lessened. With this lessening, often comes a lessening of stress that then lessens tinnitus bother. This program does not make medication recommendations nor is medication right for everyone. But it may be worth talking with your doctor about how a medication may be used to help with the secondary symptoms that so often go hand in hand with tinnitus in an effort to reduce stress.

How do you envision a typical practice implementing mindfulness therapy for tinnitus? Would you employ in combination with tinnitus masking devices? Can you bill third party payers for it? What are the start-up costs? Is there a network professionals can tap into for support and advice after they begin using it?

Patients come to us for our expertise, answers, recommendations and relief. When it comes to tinnitus and sound sensitivity disorders, statements like, “There is really nothing that can be done” and “You just have to go home and live-with-it” are false and only serve to increase stress and anxiety, both of which we know only increase the very symptom we are trying to reduce.

The audiologist’s strength is with measurement of hearing loss, education, hearing aid fitting and dispensing, ear protection, sound therapy, and the like. But what can the patient do outside of the audiologist’s office to further healing? In the past, audiologists have felt pressure to solve the tinnitus puzzle for their patients. With mindfulness-based programs, audiologists are now in a great position to empower and direct their tinnitus patients to do their own personal work of healing. For audiologists interested in introducing the MBTSR program, they can refer patients directly to to complete the tinnitus/hyperacusis management puzzle.

Hearing-health professionals have found it helpful to refer their tinnitus/hyperacusis patients directly to the website to complete on their own in between their audiology visits. As mentioned earlier, using a combination of devices such as sound generators in conjunction with a mindfulness-based course is most helpful in shifting tinnitus/hyperacusis from a “bothersome” to a “non-bothersome” sensation. During appointments, audiologists can practice their craft of measuring hearing loss, fitting devices, providing tinnitus/hyperacusis education, offering sound generators, and the like. By then referring their patients to the course to complete at home on their own, professionals have commented that the 8-week online has empowered people with tinnitus/hyperacusis to put healing back into the hands of the patient, where it largely belongs. This takes the undue pressure off of the audiologist to solve the tinnitus puzzle for their patients during their visits.
Unfortunately at this time, third-party payers are not reimbursing for the course but I have kept the cost relatively low at $325 for the full 8-week program. Agencies supporting the victims of the Boston Marathon bombings and the Musician’s Clinic of New Orleans have free use of the course for their patients and I am currently working with agencies like the VA to make the course readily available to Veterans.
The online program has a strong support network for professionals wanting to learn more about mindfulness as an approach to sound sensitivity disorders through a weekly blog published at, frequently updated resources listed on the website,, and through direct contact with the MBTSR program at

You mention habituation to tinnitus and hyperacusis. How does a mindfulness practice promote habituation?

Habituation is form of learning in which an organism decreases or stops responding to a stimulus after repeated presentations. In the case of tinnitus, the person learns to stop responding to the sound, as it is categorized as no longer biologically relevant. Under normal conditions, the body naturally wants to habituate. So when a person is faced with bothersome tinnitus (and hyperacusis) my question is always, “What is blocking habituation?” Is it fear? Is it a block due to the brain’s misinterpretation or mis-appraisal of the benign, albeit incredibly bothersome, sound?
Questions as to how to re-balance the brain for an accurate appraisal of potential threat is one that has remained a challenge for the scientific and clinical community. Drugs, techniques, and surgeries to correct misappraisal remains elusive with inconsistent relief and variable results.
Mindfulness is a proven process for rebalancing the brain. With the clear mind, that results from a meditation practice the person with bothersome tinnitus is presented with the opportunity to re-perceive tinnitus/hyperacusis for what it really is, a neutral stimulus causing no imminent bodily harm, and therefore the gates to habituation are opened to healing.

With a program called Mindfulness Based Tinnitus Stress Reduction can you explain the role that stress reduction plays in sound sensitivity disorders like tinnitus and hyperacusis?

Two things that we know for certain about tinnitus (and hyperacusis) is that stress increases tinnitus bother and relaxation decreases tinnitus bother. Studies conducted with 8-week Mindfulness-Based programs have shown evidence of a decrease in cortisol levels in subjects. Cortisol is a hormone excreted by the adrenal gland in response to stress. While it can be life-saving in short bursts when threat exists, it can also act as a poison to body tissue and brain functioning when it is left to circulate in the system when no real danger is present. This excess of cortisol circulating in the organs and brain tissue of the person with tinnitus can lead to breakdown in key brain areas needed for appraising tinnitus more accurately.
Awareness of our brain’s habitual mis-appraisal of the tinnitus sound stimulus is the tool that we use to slow down an automatic knee-jerk reaction. Awareness gives us time to pause, and make space for planning and executing a more appropriate response to whatever we are faced with in the moment.

Stress, on the other hand, is the very thing that speeds up a reaction, oftentimes, eliminating our ability and flexibility to choose a more life-affirming and well-thought-out response. A reduction in stress and a building up of awareness helps us to change an automatic ‘reaction’ to tinnitus into a more thoughtful adaptive ‘response’.

A reduction in stress paves the way to cognitive, emotional, biological, and behavioral shifts working synergistically to facilitate relief. Stress reduction is a critical piece in giving a person the space to re-perceive tinnitus sensation in a new more adaptive way. A mindfulness approach to tinnitus/hyperacusis recognizes the importance of stress reduction in un-learning old habits and creating new adaptive responses to the tinnitus sensation.

Let’s talk about the research that has been published on mindfulness based approaches to tinnitus relief. What’s the evidence supporting its effectiveness? Are there some patient populations that are more successful with it? How much time does it take for patients to experience results?

Research into mindfulness as a management tool for sound sensitivity disorders like tinnitus, hyperacusis, and misophonia, is a growing field with well-designed studies being conducted as we speak. Expect to see a lot more findings in the months ahead. Results from the initial study conducted on the 8-week Mindfulness Based Tinnitus Stress Reduction (MBTSR) course developed and researched at UCSF showed a reduction in tinnitus bother, decrease in depression and anxiety scores, an increase in overall quality of life and mindfulness in participants. Even more exciting were the results of the 12-month follow-up study that showed that tinnitus bother continued to decrease even further when participants were re-tested 12-months after the study was completed. This speaks to the long-term potential effects of a mindfulness-based approach. These results echo numerous findings of mindfulness-based approaches and there is a study underway at the University of Idaho comparing the effects of the MBTSR in-person group program with, the 8-week online version. I have listed links to published research at the end of this article for further inquiry.
In my experience, anyone who is bothered by tinnitus can benefit from a mindfulness approach, but who benefits the most is a pressing research question that I hope to have answered in the near future. For a provider to be able to pinpoint what population may see the most benefit will help with making skillful recommendations to patients and program offerings. What I have found in my own practice is that some people prefer participating in an in-person MBTSR 8-week course but others prefer to take the course in the privacy of their own homes (or wherever they have internet connection) using the online version. The online version is also well suited for the patient who lives in remote areas where tinnitus care is unavailable or for those who have transportation issues. So many of us have busy travel lives and the online course is a low-cost option, can be taken at any convenient time and goes with the participant anywhere they are.
In comparison to other tinnitus counseling approaches, the MBTSR program is relatively brief and many patients begin to see change in just days. The reason why the course is a full 8-weeks in length is that learning theory tells us that it takes, on average, about 8-weeks to really learn any new skill. We all wish there was a magic pill or safe and reliable procedure that could relieve tinnitus bother in just one fell swoop. But until that pill or procedure is developed, the MBTSR and course with its combination of mindfulness lessons, meditation practice, tinnitus education, gentle yoga, and various activities included in the course, in just 8-weeks people are well on the path to healing.
I recently received a message from a woman taking the course and she said, “After just 3-weeks of the course, I am noticing that my tinnitus is not bothering me as much. AND I’m getting along better with my husband!!” This was music to my ears because it speaks to how bringing a mindfulness approach to any and all areas of life (to whatever moment we are in) whether we are struggling with tinnitus or a relationship or any number of life-pains, approaching the moment with curiosity, openness, acceptance, and compassion for ourselves and others (all of which are a necessary component to living mindfully) we begin to live life with greater ease and joy. What we find is that people begin the course bothered by tinnitus and in no time, begin to change their perspective on tinnitus as well as all of the inevitable pains that are part-and-parcel of living.