Tinnitus is a debilitating condition for many adults… What is happening inside the brain of someone suffering from tinnitus and how does a mindfulness-based approach address the problem different than, say, conventional tinnitus maskers that some audiologists prescribe?

First let me emphasize, that the best tinnitus management approach is a broad tinnitus management approach. As a psychologist and specialist with sound sensitivity disorders a major focus of my work is on the psychological underpinnings of such disorders such as the depression, anxiety, sleep difficulty, and concentration problems blocking well-being. That said, I fully see the necessity for good audiological care as an important part of the management picture. Mindfulness-based approaches address the problem of tinnitus with (rather than as a replacement for) conventional tinnitus sound generators and there are many other tools that can be used in concert to reduce stress and promote healing. For example, while practicing any mindfulness or meditation approach I always encourage patients to use sound therapy if that helps them to relax, ease tension and discomfort.
To the question of what is happening inside the tinnitus brain, I think that Josef Rachecker, PhD of Georgetown University said it best in a recent article when he describes the generation of tinnitus as a “dysfunctional valuation process and abnormal assignment of negative meaning to a neutral stimulus” (Rachecker et al 2015). What is meant here is that the brain’s misappraisal of the tinnitus (and hyperacusis) sensation as a threat rather than as a benign body sensation is linked to imbalances in the brain’s threat appraisal system. We know through science and experience that tinnitus—in and of itself—is not a cause for alarm and can safely be habituated. The question then is, how might we reassure ourselves of this, and assist the brain in choosing the more accurate and adaptive response?
The 8-week Mindfulness Based Tinnitus Stress Reduction (MBTSR) skill-building program developed and researched with my colleagues at UCSF, teaches a meditation practice as a mental calisthenics of sorts. The awareness building practice of meditation is a way of exercising and re-wiring the brain’s learned yet unhelpful tinnitus reaction in exchange for more emotional balance and an adaptive response as to how we choose to relate to the sensation. This very process helps to clear the way for the brain to do what it likes to do naturally, habituate to the bothersome sound.
MBTSR and brain training.
A central goal of the 8-week MBTSR program is to help participants train the brain to convince the fast-acting and mis-appraising amygdala (a structure within the Limbic System of the midbrain that is associated with the fear response) that keeping tinnitus in our awareness is a waste of our energy and resources. Like the sound of a white noise machine or fan, tinnitus also can safely recede into the recesses of our mind.
Convincing the amygdala of this fact is the job of the higher developed areas of the brain. The pre-frontal cortex conducts our executive functioning tasks, including judgment, reasoning, emotional regulation, bringing awareness to certain things, and fear modulation, to name a few. This conscious part of the brain can be enlisted to exert more control. With awareness there is a slowing down of the habitual knee-jerk reaction, bringing awareness to certain processes such as an overactive fear reaction “chilling out” the over-firing amygdala.
The pre-frontal cortex is slightly slower in processing than the amygdala. This partly explains why our brains tend to place sounds in the “better-safe-than-sorry” danger category. Research in brain anatomy and physiology shows that, when directed, the pre-frontal cortex sends fibers to the overactive amygdala. These fibers are the down-regulating neuropeptides, such as GABA, that serve to “calm down” this area so that we can use reasoning to put tinnitus in the benign category, where it belongs.
Mindfulness: The Personal Trainer of the Pre-Frontal Cortex
A mindfulness-based approach, and the 8-week MBTSR course specifically, builds these new neural networks or “mental muscles”. Because many people have lived with bothersome tinnitus for years or decades, there are a lot of familiar patterns that they feel are impossible to overcome. However, with diligent practice, MBTSR teaches step-by-step skills needed to help the thinking brain more accurately determine real threats, and to calm “knee-jerk” reactions to bothersome tinnitus/hyperacusis.
A mindfulness approach to tinnitus helps extinguish the automatic fear reaction and replaces it with a letting go of attention and perception of tinnitus. The MBTSR program focuses on helping people uncover their own internal resources toward a reinterpretation of tinnitus. With practice, people with tinnitus are capable of “More Firing, More Wiring”: strengthening connections in the pre-frontal cortex for a greater, more measured, balance in daily life. This is an important step towards unraveling the Gordian Knot of tinnitus. For a more in depth description of what is happening inside the tinnitus brain and how a mindfulness practice can help transform “bothersome” tinnitus into “non-bothersome” tinnitus, visit the link: Mindfulness & The Tinnitus Gordian Knot.

Could you elaborate on the science behind this mindfulness-based approach? What is happening inside the brain of a patient before and after this intervention?

What is happening inside the brain of the person who practices mindfulness is a hot topic in research these days. With new technologies in brain imaging techniques, we are able to see changes in the brain like never before. Compelling studies support the argument that mindfulness can lead to more adaptive changes in the brain as a person responds to old and new stimuli. One example is research conducted by Sara Lazar and her colleagues at Harvard suggesting that meditation leads to cortical growth and thickening in parts of the brain associated with focal attention, fear, and emotion regulation. The study revealed that experienced meditators versus non-meditators were more effective in sending information to unconscious areas of the brain, areas that exert influence on our ability to calm ourselves down when we might have an over-reaction of fear to a benign event or body sensation, as is the case with tinnitus.
Neuroimaging findings support the Hebbian theory: “Neurons that fire together wire together.” I emphasize that it is the very ‘awareness’ that shines the light on maladaptive thinking habits and behaviors giving us more conscious control to choose more adaptive choices. When we practice bringing awareness to our thoughts and actions (ie, regular yoga and meditation), we can strengthen connections within the brain. These connections facilitate better opportunity and more space as to how we choose to respond to our experience with tinnitus. Such practice contributes to creating new tinnitus neural networks, ones that can help to keep the brain in balance. Clearing the way for the natural process of habituation to take place is the result.

You’re an expert on tinnitus and mindfulness based approaches to healing. Let’s start by discussing the concept of mindfulness. Where does it come from? In general terms, what science supports the efficacy of mindfulness-based approaches to address any medical condition?

While the practice of mindfulness meditation has its origins in Buddhism dating back as far as 2500 years, meditation is actually a natural human capacity and can be found across many religions across many cultures throughout history. The practices taught in present-day mindfulness-based approaches to medical conditions and well-being as discussed below are of a secular nature and do not require any religious beliefs, practices, or lifestyle changes other than practicing daily mindfulness meditation.
I see mindfulness as the skill of keeping sensation, emotions, and thoughts in moment-to-moment awareness without clinging to the habitual (and often unfounded) judgments that our mind tends to create. An important principle of mindfulness is that sensations, thoughts, or feelings, be they perceived as pleasant, unpleasant, or neutral, are not actively ignored or avoided. Instead, there is a relaxation of efforts at control, a tolerance for whatever discomfort arises as a temporary and passing momentary experience, a purposeful maintaining of attention on the present, an allowing of feelings to be just as they are, while observing experience with openness, curiosity, and acceptance.
The practice of mindfulness trains the mind to be with whatever sensations, thoughts, and feelings arise without becoming too attached to whatever is perceived. Those of us working with people with sound sensitivities in our practice know that this is particularly relevant for the person experiencing bothersome tinnitus. The person with chronic bothersome tinnitus rarely experiences the unpleasant sensation of tinnitus in isolation. Almost always, the tinnitus sensation is wrapped tightly in a cascade of thoughts, judgments, memories, fears, emotions, sadness, regrets, beliefs, and feelings about past, present, and future experiences living with this chronic symptom. Tinnitus gets wrapped in a Gordian Knot of our mind’s own creation and all roads to habituation are blocked (habituation will be discussed in more depth later in this interview).
Bringing awareness to how we may, in fact, be helping to create our own suffering—our own Gordian Knot—is not an easy task. Much like going to the gym to build a muscle, a personal trainer can guide us, but ultimately we have to do the heavy lifting to reach desired results. However, with a mindfulness practice, we can train our minds, rewire old thinking habits, modify our behaviors and reactions, and ultimately, learn to live with tinnitus with greater ease.
The widespread acceptance of mindfulness in modern life as an approach to healing stems from clinical trials demonstrating its effectiveness for a range of illnesses. It has been applied with success to a growing number of conditions including chronic pain, depression, anxiety, sleep difficulty, stress, fibromyalgia, disordered eating, chronic fatigue, psoriasis, symptoms associated with cancer, and the list goes on and on. Clinical trials suggest a positive shift in “whole-person health” with changes in relaxation, cognition, biology, and behavior. The focus of my work has been on making mindfulness accessible to the field of audiology to re-balance the brain for tinnitus, hyperacusis, and misophonia relief.

Mindfulness: Becoming your own best friend

How many of you out there would say that you are “your own worst enemy”? If you answered “yes!” you are in good company. Our ‘inner critic’ with all of its judging, comparing, and striving can creep into everything we do, especially into how we relate to ourselves when we experience moments of bothersome tinnitus and hyperacusis. Left unchecked, our minds can go down some very dark tinnitus roads. You may catch yourself thinking such things as:

“I must have done something to deserve this.”
“How come I’m the only one I know that has tinnitus?”
“Bad things always happen to me.”
“I’m so weak. Why can’t I just be done with it?”
“Just my luck—I get tinnitus.”
“My tinnitus is back. Here’s proof that I’ll never get rid of this.”
“It’s my fault, I should have taken better care of my hearing when I was younger.”

And on and on the list goes…

We began this course emphasizing how we may bring curiosity, openness, acceptance, and compassion to our moment to moment experience with tinnitus. As you become more skilled in your practice, perhaps you begin to notice changes in how you not only relate to tinnitus, but how you relate to ‘your self’ as a whole. Do you catch your ‘inner critic’ being overly judgmental in some other area of your life? Perhaps you can bring awareness to the full gamut of these well-worn, destructive, mental habits? Perhaps you can bring awareness to how you might be comparing yourself (favorably or unfavorably) to others? Just the awareness itself of the mind’s habits is the tool that opens the door to changing a knee-jerk reaction into a ‘life-affirming’ response. As you bring radical awareness to the habits of the mind, you may begin to see a shift from being your ‘own worst enemy’ to being the kind-hearted and compassionate friend that is our best-self.

Tinnitus, Anger, Blame, and Fear: Wrestling with Challenging But Normal Feelings

It is very common for a person who experiences tinnitus (hyperacusis) to react to this very unpleasant sensation with feelings of Anger, Blame, and Fear. While these feelings can be intense and feel destructive they are also very normal reactions to feeling that something has been taken away, before we are ready to let go. In the case of tinnitus, what is often experienced as being taken away, is silence. Perhaps you feel anger that you had never been warned of the dangers of exposure to loud and persistent noise over time in the work place, perhaps you blame yourself, perhaps you are angry at our medical system for not having yet found a cure, maybe you are fearful of what life may be like in the future should the tinnitus not go away.

While these feelings can be very intense and uncomfortable, if they are there for you, try to allow them be there. Challenge yourself to acknowledge them with curiosity, openness, acceptance and compassion for yourself. It is important to address them in order to diffuse their intensity. This is especially the case if we feel that something or someone had a direct hand in causing the tinnitus discomfort.

While practicing, if any of these normal (but often uncomfortable) feelings come up, simply acknowledge that they are there in this particular moment. Start to notice where in your body you might be experiencing these feelings. For example, anger can feel like a lump or pressure in the throat. Fear can often be felt deep within the chest. Wherever the feeling arises for you, just notice it. No need to try to change the feeling or make efforts to push it away. Challenge yourself to just be there with it. Observe it without judgment and see how it changes in intensity.

If during or after completing this course, you continue to feel intense feelings of anger, blame, and fear, it is recommended that you seek in-person professional help from a counselor to address these very normal but very difficult emotions to wrestle with.

For more information go to MindfulTinnitusRelief.com to begin healing.