The psychology of tinnitus & TBI

 

Discovering Tinnitus Through the Cochlear Implant Center
So, you know, I was working at the cochlear implant center at UCSF several years ago and, you know, as a clinical psychologist, it was my job to do an evaluation of everybody getting a cochlear implant. Because if you think about it, you have to be a good cochlear implant user. So, if something is going to block you or stop you from being a good user of a cochlear implant, it was my job to see if there was something going on—depression, anxiety, a whole number of things that we could work on so that you would be a better user of it.

So, really, a smart job.

So, we were getting obviously deaf people coming through, and so many people were complaining of tinnitus, and it seemed like none of the doctors wanted to touch it. You know, it was like, "Oh, yeah, yeah, yeah. I know you have tinnitus, but you're really here for the hearing loss part, so let's shove that aside, or go home and live with it," or what have you.

And so, me being who I am, that made me curious. And so, that really started my dive in.

Now, at the same time, I was learning about mindfulness-based stress reduction as an eight-week program. We can get more into what that is and how I've applied it to tinnitus. But we were seeing amazing results with chronic pain with that. There was a recent study that had come out that was showing great results.

So, anytime I work with somebody with tinnitus, I'm thinking, "Gee, I wonder..." Anytime I see research being done, I should say, with chronic pain, it makes me wonder, would this be helpful for somebody with chronic tinnitus?

So, I blended those two together, I guess—knowledge of tinnitus with a mindfulness-based approach. And here we are today.

And, you know, it's been a long road getting me to us today, but I have a lot to share about what I've learned over the thousands of hours that I've worked with people with chronic and bothersome tinnitus.

Understanding What Tinnitus Is
Mandy: Yeah. Awesome. And like I said, it's a question that comes up very frequently with my patients. And again, I see all TBI patients, so that's the population that I see all the time. And some of them do comment that it's bothersome and some not.

But for our listeners that maybe don't necessarily know what it is, because every once in a while I'll ask my patients if they experience different things and they don't know what I mean. So, can you describe what is tinnitus?

Dr. Gans: Yes. Well, before we go there, I just want to let you know that actually there's a large number of people, brain injury or not brain injury, that are experiencing tinnitus.

So, you know, this is what I'd love to do today. I really want to do three things.

Number one, help everybody feel less anxious around tinnitus.

Number two, make sure that anybody that listens to this becomes an expert in what tinnitus is. And I mean a real expert. Humans function better when we understand. So, hopefully today we'll get a chance to kind of work out the educational part—the accurate educational part.

And then number three, talk about ways to shift it from bothersome to non-bothersome. And that has a lot to do with stress reduction, et cetera, et cetera.

So, you know, that's a real critical part of working with people with tinnitus.

Now, let's go to the definition. So, let's work on number two for a moment.

So, let me define tinnitus, and it's not complicated. Nothing I say today is rocket science. And so, yes, you could say, as I'm a psychologist, I'm coming at this from a cognitive behavioral approach or the psychological approach.

I want to back up for a moment and say that everything I'm saying today is coming from a logical place. Okay? So, when I'm talking about tinnitus and what it is, I'm being logical. And if I say something that doesn't feel logical, you know, please interrupt me so that we can go back to it and make it make sense.

This is not rocket science.

Now, back to the definition. Tinnitus is a benign body sensation that the brain thinks is important to pay attention to when, in fact, the brain can allow it to go back into the background where it belongs.

Okay, so I'm going to say that probably 15 or so times today. But tinnitus is a benign body sensation that the brain thinks is important to pay attention to when, in fact, it isn't.

And so, we can talk about why would somebody pay attention to something that's not important. That's certainly worthwhile. But the word benign—the word benign doesn't mean good. The word benign means that it is not an indication of a greater illness.

Okay? Now, nobody wants, for example, a tumor, but we sure hope it's benign. Okay?

Nobody wants tinnitus. I've never met a single person, patient, walk of life that ever has wanted tinnitus. But we can all take a deep breath knowing that it is benign.

And so, that's where we start our work: from a place of understanding that nothing's broken. There's actually nothing to fix. But the brain has misunderstood a benign body sensation.

And when we connect any body sensation to fear or frustration or fascination—but in the case of tinnitus, it's usually fear—like, "Oh my God, this is caused by my TBI," or, "Gosh, if I had never been exposed to that loud sound," or, "How am I going to keep my job? You know, how am I going to get sleep? Oh my gosh, maybe I need to go back in and make sure I don't have a brain tumor."

So, you know, a lot of stories can get wrapped around this benign body sensation.

And so, when we connect it to fear, what happens? The lens of the mind gets locked and loaded.

Okay. So, our job is to unravel those stories, open up the lens, so that we can start putting tinnitus where it belongs—in the background.

Why Tinnitus Is Bothering Some People and Not Others
Mandy: So, what from the patient side of things would they experience with tinnitus? Can it be a different experience for one person to another?

Dr. Gans: Absolutely. That's a great question.

So, let's talk about numbers. And, you know, we were talking a little bit before about how numbers can be just so misleading. But I'm just going to throw out some numbers. Do with it what you will.

So, I can speak more specifically about the TBI group, but I'm just going to talk about tinnitus in general.

So, here in the United States, 50 million Americans experience tinnitus. Now, that's a huge number, but it's such a big number, it doesn't really give us any good information. Now we have to look a little bit more carefully to see what we're really saying here.

So, of that 50 million, 20 million are bothered enough by their tinnitus to go to their doctor and say, "Oh my God, this is horrible. I can't live like this. Something is wrong."

Now, if you and I do the math, that leaves 30 million Americans that are walking the streets of our country. Here's—just, we're just talking United States right now—walking the streets of this country with tinnitus, and they don't care.

So, in my opinion, you know, everybody's like up in arms, "Where's a cure for tinnitus? Where's the pill? Where's the procedure?"

And I'm like, well, if you have a benign body sensation for the rest of your life and it doesn't bother you, isn't that the effective cure?

So, we have to first understand what we're really talking about here.

So, the work that I do is not to help somebody get rid of tinnitus. Now, they very well might get rid of tinnitus, but I don't like working on things I don't have control of. That doesn't—that's just not interesting.

So, yes, they might get rid of tinnitus, but if they have it for the rest of their life, my job is to help people shift from the 20 million—we're going to call it the bothersome group—into the 30 million non-bothersome group.

And I ask my patients, if you have a benign body sensation for the rest of your life and it doesn't bother you, can you be okay with that?

And invariably, the answer has to be yes, because God knows we've got a lot of benign body that we're not really fond of, but we safely push them into the background because we have bigger fish to fry.

But the TBI group is a unique group because it really highlights, or I should say it kind of really zooms the lens in on something that maybe it shouldn't be zooming its lens in.

And so, I also want to say that the work of shifting it from bothersome to non-bothersome is not easy. It's simple but not easy.

So, I also—I don't know, I mean, to put it in these terms, I can kind of sound like a jerk when I talk about tinnitus because, you know, here I'm like, "Oh, it's a benign body sensation. Let's not get anxious about it. Let's get educated. You know, oh, it's a paper tiger."

I mean, I can sound—I mean, to somebody that is bothered by it, that can sound very insensitive.

But let me say I've sat now for thousands of hours with people with bothersome tinnitus, and it's just very hard for me to get excited about something that's benign.

And so, I do want to say it's not lost on me—and again, thousands of hours with patients—it is not lost on me that this is devastating for some people.

But again, it's hard for me to get excited about a benign body sensation and the fact that everybody gets better.

Anybody—anybody can shift tinnitus from the 20 million bothersome group into the 30 million non-bothersome group if certain things are followed.

So, we'll hopefully talk a little more about that.

The Brain as a Prediction Machine
Mandy: Yeah. And maybe now's a good segue for that. What's—what makes it bothersome to one person? What makes it not bothersome to another person?

Dr. Gans: Right. All right. So, this is—let's go back to what causes tinnitus.

I mean, again, you know, humans function better when we understand things. So, when there's something going on with us, I mean, you know, and it can be something really difficult, but if we understand what's happening, we can plot our path forward.

And so again, there's that educational piece of tinnitus that's so important.

So, what causes tinnitus?

Now, one thing that we can look at are—we have to actually—we have to pull our camera back and start paying attention to the mind and the brain.

So, let's talk about the brain for a moment.

The brain is a prediction machine. Its number one job, obviously, is to keep us alive. But the brain is a prediction machine and it doesn't like gaps. The brain loves to fill in gaps.

Okay, here's a great example.

So, humans—we have a blind spot. It's where the retina hits the back of the eye. We have a blind spot in our field of vision that we've had since we were born, since we opened our eyes for the first time.

Now, I don't know about you, but I can't even find my blind spot. I know I'm putting my finger in front of my face because I remember in psychology in college, they would show us how we could find our blind spot.

But so, the brain does us a favor. It says, "You know what? That blind spot, I've always seen it. It's not that interesting. And, you know, we have this beautiful sunset in front of us. Let me just do you a little favor, and I'm going to just fill it all in so that you can look at the horizon without a big black hole in it."

So, again, the brain is really working behind the scenes to fill things in.

Phantom Sensations and the Five Senses
Now, let's talk about the five senses. Now, there's many more than five senses. In fact, I was reading recently that they've counted 10 different senses, but we'll talk about the five traditional ones.

Okay? So, you have touch, taste, smell, vision, and hearing.

Okay? So, touch. Well, I'll talk about phantom limb sensation.

Okay? So, here's my hand right here. My hand is literally here, but my hand is really here because this is where all the sensations come to. This is where all the commands come from. And this is where all the memories of my hand are, right here.

So, boom. Let's say I cut my hand off. God forbid I cut my hand off. And then my brain says, "Wait a minute. Where's my hand? I've always had a hand. It has to be here."

And so, the brain doesn't like gaps. It loves to fill things in, but it's noticing a gap. There's something missing. Something is different. I can't find my hand.

So, what does the brain do? It starts to search and search and search and search and search. And in that search, it gets really, really excited, and boom, it creates the sensation as if the hand were still there.

You know, it's unfortunate if it's phantom limb pain. It's not always pain, but it's, you know, certainly a sensation. But in and of itself, it's benign.

Nobody's ever died from a loss of—well, you can certainly die from loss of a limb, but certainly if you bleed out. But if you control the bleed, and nobody would choose to lose a hand, but in and of itself it is not going to, you know, create further problems as far as death and what have you.

So, anyway, let me move on to some other senses because I think understanding all five is important.

So, now we have the sense of smell. Doctors report that when patients come in and they've lost their sense of smell, they'll come in reporting, you know, "It's so weird. I know I've lost my sense of smell, but I'm having these smell sensations," almost phantom smells.

And so, the brain has lost the ability to smell. It's always been able to smell. So, those smells have to be here. So, the brain searches, and in the absence of that ability to smell, the brain turns up the volume and creates that phantom smell.

Now we're going to go to taste. Same properties. You lose a sense of taste. The brain searches for those taste receptors that it used to have, and boom, boom, boom, it creates this phantom sensation of taste.

Now let's go to the eyes.

Now, there's a syndrome called Charles Bonnet syndrome. Anybody's welcome to look that up. Where when somebody loses vision, their brain again is kind of like, "Okay, that's weird. I've always been able to see," and the brain will create these phantom visions, so to speak.

It can happen with macular degeneration. It's not—I wouldn't say it's common, but it happens. It's called Charles Bonnet syndrome.

And now let's go on to our fifth sense, the sense of hearing.

Hearing Loss and the Search for Missing Sound
Now, humans—every human loses hearing. That's, you know, it's kind of the aging process.

Let's say it's, you know, not—ears are designed to last. I mean, they—but erosion happens.

And so, we do know that maybe after—I mean, I'm again throwing a number out that is variable—but let's say after the age of 20, you could argue that every human out there has some form of hearing loss.

Okay? And so, when we lose hearing—and it can be severe hearing loss, obviously, but sometimes people can have hearing loss that doesn't even show up on an audiogram.

And actually I'll tell you why that is.

Because humans—and when we go to get our audiogram, we're getting our hearing test. They're measuring us from 250 hertz to 8,000 hertz. But humans hear all the way out to 20,000 hertz.

Okay? So, the audiologist is like, "You know what? This is where our hearing world is. This is where our speech sounds are. This is where emergency sounds are. This is where nature sounds are. This is where music is. All the hearing that we love to have and need is really between 250 hertz and 8,000 hertz."

So, they're not going to measure you behind or beyond 8,000 hertz because, you know, it's just going to take more time and it really doesn't add up to much.

However, if you looked—let's say somebody had normal hearing—they would take out their audiogram, if they took their audiogram out even further, it would—the hearing would start to go down, down, down, you know, somewhere between 8,000 and 20,000.

Wow.

That's my way of saying that hearing loss is normal and natural.

And you don't get a hearing aid or you don't go to an audiologist unless you're having—if you're struggling with communicating or hearing things in the environment that you used to.

Now, that said, let's go back to the sense.

So, everybody experiences hearing loss and so the brain says, "Wait a minute, that's so weird. I used to be able to hear that frequency. Where is it?"

So, what does the brain do? It starts to search and search and search and search, and it gets really excited because it cannot find that frequency.

So, it searches harder and harder and harder and boom, it creates a sensation that we call tinnitus.

So, when something is happening five out of five, 100%, it makes us wonder, well, gee, you know, maybe it isn't the ringing. Maybe there's something behind the ringing. Maybe there's something about the brain that is going on.

And so, here we are getting locked and loaded on tinnitus when really it's just properties or the way the brain functions.

The Tinnitus Trifecta
Now, why would somebody develop tinnitus and somebody else wouldn't?

Well, that depends on three things.

Okay? So, here we—I have this beautiful trifecta.

So, like if I was to go bake a cake, I would need to, you know, I could put in chocolate, I could put in strawberries, vanilla, all kinds of great stuff. But at its base, it has to have certain key ingredients.

So, now with tinnitus, same thing.

Now again, every patient I see, everybody with tinnitus, all 50 million of them plus, all have unique things about them.

However, for the ones that fall into the bothersome category—now, I'm not talking about the non-bothersome category. They don't come in to see me, so I don't know as much about that group.

However, with this bothersome group, every single person that falls into the bothersome group has at least these three things in common.

Okay?

So again, in the service of education, in the service of the importance of understanding something, I'm going to tell you what those three things are.

And, you know, for any listener that has bothersome tinnitus, I want you to see if you see yourself within these three things.

Okay?

So, number one, everybody with tinnitus—I think this is probably true of all groups, but everybody with tinnitus has to have some form of hearing loss.

It can be literal hearing loss where you need hearing aids or a cochlear implant, or you're struggling with hearing, or it can be what they call hidden hearing loss, maybe in the highest of high frequencies.

However, this is a necessary ingredient. You have to lose something in order for the brain to search for it, right?

So, this is a necessary—I guess it's almost like the match that starts the fire.

So, first and foremost, you have to have—you have to lose something in order to search, and that would be in the form of some form of hearing loss.

Number two, stress.

Now, that is something we're going to talk more about. I can say with great certainty that traumatic brain injury is, for some people, the biggest stressor of their lives.

Okay? So, we have that stress component.

And number three, every single person that falls into the bothersome group has an amazing personality, is what I call it.

Okay? Now, they are—and they—it is an amazing personality because the person I'm going to explain to you, they are functioning. They're, you know, something that this personality is something that they love about themselves.

So, we're not here to get rid of this personality, but we're here to shave off the underbelly that's pulling them down.

And so, I also want to get into a little bit of the subtle differences between somebody with TBI and somebody without TBI that gets tinnitus. So, I am going to clarify that, but let me explain this amazing personality.

Okay?

So, everybody 100% of the time with bothersome tinnitus is the kind of person that is very alert, aware, alive, and vigilant.

They don't miss much.

Okay? And if they spot a problem, for example, maybe it's something going on with their body, maybe it's, you know, something going on at work or around them. If they spot a problem, they latch on to it and they have trouble letting it go until they figure it out.

TBI and the Brain as an Orchestra
Okay. So now, why I pause a little bit and say there's a slight difference with the group with TBI is that a brain injury is such an amazing stressor on the body.

And, you know, there's a lot going on, and the body is trying to find equilibrium. And, you know, I think of the brain as an orchestra, okay, like a symphony—a beautiful symphony.

And, you know, we have the occipital lobe, the parietal lobe, the limbic system, the auditory cortex, all these different beautiful parts of the brain, and it's almost as if they're different sections of an orchestra.

Now, each section in and of itself is beautiful, phenomenal. I mean, just the human brain is—I can't say enough about it anyway.

Right. So, but when one of those sections is playing out of tune, the symphony doesn't play. The magic doesn't happen.

And so, that's how I see people with traumatic brain injury: their brain is in this disequilibrium. And, you know, there can be damage and the brain is going to have to adjust and the emotions are going to have to adjust and create a new form of balance.

But in that process of tuning the instrument, tuning the orchestra up, there's an awful lot of stress going on. And one part of the brain might be not communicating with the other part of the brain or not able to communicate with another part of the brain, and we have all the things that can happen.

And so, the person with a TBI is such—their brain is under stress.

Now, it's not to say that you can't find your balance again, and it might not be the balance that you had before the TBI, but it is—you are being given a life's goal of finding your way, of tuning your own orchestra.

And so, you know, doing that can be very, very difficult.

And you become—you know, doctors will say, "You know, how do you feel now? How do you feel now?" And you're constantly testing yourself. You know, "Gosh, am I able to do this now? Or how do I feel now?"

And all of a sudden you're checking your body and you're like, "Gosh, you know, that feels different and that feels different, and then my God, what's that sound? Oh my God, this must be because of the traumatic brain injury."

When really, it's somebody who is picking up on something in the subconscious, the amygdala.

I mean, let me talk a little bit about the brain for a moment.

The Three-Part Brain Model
And I'm going to talk about the brain in three parts. Again, the number three comes up an awful lot.

So, we have the brain stem, and that's things like heartbeat, respiration, sleep-wake cycles. I mean, all of the things that our brain doesn't have to consciously be thinking about, and it kind of does it for us.

Imagine if we had to think about every single breath. I mean, we wouldn't be able to get out of bed in the morning. We'd be very, very busy just trying to, you know, create the next breath.

So, our brain stem does us a big favor and it says, "You know what? You've got bigger fish to fry. You've got more interesting things to think about. Oh, I'm going to offload that responsibility. I'll take care of those kind of basic things."

Now, so it keeps it subconscious.

Now, the second part of the brain to develop is the limbic system, or the emotional area of the brain.

And inside the limbic system, there's this almond-shaped area, small little almond-shaped area, called the amygdala.

Now, the amygdala's job is to take in information from the external world, take in information from the internal world, and make a decision.

And so, the decision that the amygdala makes is: Is this sensation, is this experience, a danger or a potential danger? Or, "I don't know what it is, so I better keep it in the danger category until I figure it out."

Or is this sensation or experience benign, boring, not interesting, and not really relevant to what I'm trying to accomplish in this moment?

So, it puts it into the benign category and it goes into the background.

Okay.

Now, what happened on the first day of somebody noticing their tinnitus is their amygdala picked up on this signal and it, you know, the brain was searching for a sound that it wasn't able to hear and the silly brain is filling in, you know.

So, the amygdala picked up on that sensation and said, "Alert, alert, potential danger. Oh my God, this could be a brain tumor. Oh my gosh, this could mean you're losing your hearing. We better check this out."

All of a sudden, it gets wrapped up in the story and it hits the fight-or-flight response, the autonomic nervous system.

And then one more big step is we have the thalamus.

Now, the thalamus is, you know, again, I'm really bringing things down to the basic level, but it's almost a gateway between the subconscious and the conscious when it comes to things that the amygdala finds as dangerous.

For example, if the amygdala sounds the alert, alert, alert, something dangerous, the thalamus, the gateway opens and tinnitus goes from the subconscious into the conscious mind, into the cortex, into the prefrontal cortex, or into awareness, let's say, conscious awareness.

And so, this is my way of saying, oops, the amygdala made a mistake.

Your silly brain made a mistake. And it, by mistake—and for good reason, somebody who's under an awful lot of stress—the brain makes a lot of mistakes when we're under stress.

And that's why this part is so important in healing with tinnitus, because, you know, humans don't function so well when we're under severe, severe stress. We're more likely to react rather than respond.

Okay.

So, what has happened is the amygdala again has taken—has it made an error, and it put an otherwise benign body sensation that never should have gone into the consciousness of a human being, and it took it and it said, "Oh my gosh, this could be bad. We better make the brain alert."

And now you're hearing this sound.

So, my work, or the job of anybody with bothersome tinnitus, is to disengage tinnitus from fear.

Let's find out what it really is and let's call it a paper tiger. It looks scary, but it's made of paper. It's benign.

We can all take a deep breath knowing that this is not an indication of a greater illness. This is simply, darn it, a mistake that the brain made under times of great, great stress.

And so, again, it's—you know, I can be very blasé about this. This is simple but not easy.

Using the Brain to Change the Brain
But we can use the third part of the brain to develop—the prefrontal cortex.

Okay, this is our conscious mind. And this is where all the magic happens.

We can use this part of our brain to chill out the subconscious amygdala that is overfiring.

And so, by even just listening to this talk that we're having today, you can take all that accurate information into your prefrontal cortex here.

And so, when the amygdala starts to rear its head and kick, you know, the tinnitus into overdrive, you can say:

"Wait a minute, wait a minute. I don't have to like this, but I do remember that when Jennifer explained it, it's just my silly brain searching for a sound that it's no longer able to perceive. I am safe. Nothing is broken. I'm not going to lose my hearing. I don't have a brain tumor. You know, that was just my silly brain getting all crazy there. I can take a deep breath knowing that I am safe and that my brain is making an error.

"And I can correct that error by speaking the truth to myself that I'm safe, that again there's nothing broken, and that—how can I help myself in this moment in light of the fact that tinnitus is bothersome?"

And that should always be the question: How can I help myself in this moment?

And let's talk about how do you help yourself in this moment? I mean, that, you know, I like—I said at the beginning, I sometimes I'm like a fire hose once I get started on this topic. I can't—

Mandy: But, you know, Mandy, please ask a question or stop me or keep me going, whatever.

Why Sound Can Help
Mandy: I'm kind of curious because so many people, when they—they have kind of come to the conclusion that this is their thing and they're going to have tinnitus, and whether or not they've identified it as bothersome or not bothersome anymore at this point, they're running their fan all night long or they're doing some kind of white noise.

Why then does that not work to fill in that space of sound?

Dr. Gans: Well, because think about the human ear. It's so—I mean, it's magic. It's magic. And, you know, we can try as much as we want with these really high-tech hearing aids and cochlear implants even, and there's no replacing Mother Nature.

Okay? So, you know, these external sounds that we put on are wonderful.

'Cause what we said before is that, you know, the brain is searching for sound that it's no longer able to perceive. Meaning that the ears love to hear.

In fact, when they can't hear, they create sensations of hearing.

So, we want to give our ears something to hear because that calms us.

So, somebody with bothersome tinnitus that wants to just kind of take the edge off? Yeah. Put on a back—, you know, don't be in a quiet room. You know, put on a fan, put on some music.

Anything that you find relaxing is going to be helpful.

And that comes to a rule of thumb that I like to share when it comes to tinnitus:

Stress increases tinnitus bother. Relaxation decreases tinnitus bother.

Okay? So, stress increases tinnitus bother, relaxation decreases tinnitus bother.

Now again, that's not rocket science. Everything bothers you more when you're stressed. Nothing bothers you so much when you're relaxed.

But this is an important, important rule to understand when it comes to helping yourself with tinnitus.

So, what is really happening is, you know, the tinnitus is locked inside the fist and it's getting wrapped up in this story, and the lens has gotten locked and loaded on it.

And the person with bothersome tinnitus is now walking through life only hearing tinnitus.

And so, what's happened is they're stuck.

And by unraveling the stories, or the glue around this beautiful telephoto lens, we can start to open it up. And yes, tinnitus might still be there, but it's within the context of everything else around it.

So, I call—not, you know, not again to be flippant here—I call tinnitus a stuck disorder because the lens is stuck.

You don't have accurate information as to what tinnitus is. So, as far as you know, it could be a brain tumor. "Oh my God, this is the end of the world."

And so, but once we get educated and we realize, actually, nothing's broken. Your silly brain is searching for a sound that it's no longer able to perceive.

If you have significant hearing loss, go to your audiologist, get a really good hearing aid.

If you've got, you know, severe to profound hearing loss, you might be a candidate for a cochlear implant.

So, there are things that you can do to help yourself bring in more sound to your ears.

But in and of itself, it's, you know, you're safe.

And so, again, stress is—you know, the stress is really tough because, well, I'll talk about Viktor Frankl.

Creating Space Between Stimulus and Response
He was in the Holocaust years and years and years ago, and he became a psychiatrist and he wrote a book called Man's Search for Meaning.

And in that book he said, between every stimulus and—I'm going to bastardize the phrase, but this is the gist of what he said—between every stimulus and response is a space, and within this space lies our freedom and our choice.

Okay.

So, between every stimulus and response is a space, and within this space lies our freedom and our choice.

And so, anybody with bothersome tinnitus, and certainly anybody with traumatic brain injury, is really living life this way:

Tinnitus reaction. Tinnitus reaction. Tinnitus reaction. Tinnitus reaction.

There's no space. There's no freedom. You're going on knee-jerk reactions.

Okay.

And so, what we're trying to do with the person with bothersome tinnitus—and again, I can go into more effective ways of doing this—is help them to create some space, and we do that through reduction of stress.

And education is stress reducing. So, that's part of the picture so that they can choose how they want to respond to tinnitus.

So, they can choose new ways of relating to tinnitus.

And I would venture to say that, you know, knowing what everybody now knows about tinnitus, you wouldn't react to it in the old ways.

You would be able to create—take a deep breath and create some space and choice and freedom enough to say, you know something, maybe I can ask myself, "How can I help myself in this moment?"

Okay.

And so, you know, again going back to the orchestra, you know, the human brain is an orchestra.

And even people with traumatic brain injury, they still have a beautiful orchestra up here.

There's always—as long as we're breathing, there's more right with us than wrong with us.

So, whatever is going on here, we owe it to ourselves to tune our orchestra.

Like, I love to play guitar, and if I start with my, you know, a band or something and I start playing without having tuned up my own instrument, I mean, I would get kicked out of the band very, very quickly.

Okay.

So, who do we think we are to leave the house in the morning, or to enter into the next moment, or even into the next hour, without having tuned our own orchestra?

And so, that's where something like—and now there's many ways to tune your orchestra, I'm sure, and everybody has their individual ways—but one way that I have found through my research and throughout the years, obviously, number one is education.

If you—I think of tinnitus on a spectrum of one to 100. Number one is education.

Once you're educated, you can move forward in the list of things you can do.

If you don't get educated, you don't get to pass go.

But again, we're all educated now, so let's talk about one—or two to 100.

Mindfulness Meditation and Tuning the Orchestra
Now, one tool that I like to introduce people to is using mindfulness meditation.

You can see here in the bottom left here, MindfulTinnitusRelief.com.

Whether you have a TBI or not, this course is an eight-week course that helps people do the three things that I spoke about at the beginning.

Number one, helps you to feel less anxious around tinnitus.

Number two, it makes sure you're an expert in tinnitus. Every lesson has a lot of education, and whatever you know about tinnitus, it goes even deeper.

And then number three, what this course does is it starts you off on an eight-week mindfulness meditation journey or program—

Mandy: So that you can tune the orchestra of the mind.

Dr. Gans: Now, meditation can often get misunderstood.

Meditation doesn't fix anything. It was never designed to do that. It wasn't meant to do anything for you.

But what meditation does is it helps us to tune the orchestra of the mind.

And the first way that we can do that is through awareness.

And so, anybody that has taken or has practiced meditation knows that it is an awareness-building exercise.

And from that place, you can start to make responses. You can start to choose how you're going to respond to whatever is in front of you.

No matter what's in front of you, you will be able to, you know, once you understand the old reactions, you can say, "Oh, I'm not going to do it that way this time."

Instead, I'm going to choose a more life-affirming way of responding to whatever is bothering me.

So, mindfulness meditation is really the third part of the course, is teaching people how to tune the orchestra of the mind.

And that, again, you know, hearkens back to the stress—the stress part that is, you know, again, hearing loss, stress, and the amazing personality.

So, it's all—it all makes sense in its entirety. It's all pieces of this beautiful puzzle.

And, you know, whether again you have TBI or really anything, it's really important to tune your orchestra.

And what I find is that the fire below tinnitus is anxiety.

Anything—anybody with TBI is, you know, is all of a sudden being pushed into a world that they've never been in before, and that naturally or unnaturally, whatever, causes anxiety.

And so, tinnitus is benign, but the fire below it is a picture of anxiety.

So, once through education, through stress reduction, we move the tinnitus off to the side, we can start to look at the real root, the real problem, which is anxiety.

And that, you know, and that is the frontier that we need to pay some attention to.

Can Mindfulness Make Tinnitus Worse?
Mandy: Yeah. So, a few weeks ago on the show, I had another gal trained initially in mindfulness-based stress reduction who was talking about how sometimes after a brain injury, we have to be cautious because that mindfulness can backfire on us and cause more problems.

Is there ever a risk that once you start the training for the tinnitus type of mindfulness that it could make the tinnitus worse?

Dr. Gans: No. No, no.

Well, first of all, tinnitus doesn't get worse.

You either have tinnitus or don't have tinnitus.

So, you know, when people say, "Oh, my tinnitus is louder," it's not that it's technically louder because it has nothing to do with the ears or, you know, it's really the brain.

It's—it is louder isn't really the right word to use because what's really happening is your lens is just getting tighter around it.

So, when something, you know, when we focus deeply on something, it becomes brighter.

Okay? The backdrop, you know, everything floats away and all we see is whatever we're, you know, is the tinnitus.

So, tinnitus doesn't exactly get louder.

I actually, you know, it's probably against semantics, but I don't necessarily agree that mindfulness meditation makes anything worse.

Now, you know, we can feel so anxious, we can feel so broken, we can feel so depressed, we can feel whatever we feel such that, you know, we can get stuck very easily.

But I don't think it's meditation that's creating the problem.

I think it's the fact that there's a lot of things that need to be attended to at once.

And usually, just immense amounts of stress can be, you know, pushing us into old reactions that are making it, for some people, really difficult to function.

And that might be a case in which, you know, it's important to bring in the medication, you know, for people with bothersome tinnitus that are—you know, the anxiety is such an overwhelming factor that they can't even take in the accurate information.

And that can happen when you're so tightly wound around something, the brain can't get to that higher order of thinking and take in accurate information as to what tinnitus really is.

You know, there's Zoloft and Lexapro, two SSRIs that are excellent for the top three complaints with people with bothersome tinnitus, which is anxiety being primary, depression, and sleep difficulty.

So, you know, these are also wonderful drugs because they're—they don't take away anxiety. Simply lower the—you know, you don't pop the switch so much.

And I call it the difference between lying on a bed of nails and lying on a mattress.

You know, these SSRIs in particular, Zoloft and Lexapro, are excellent for people with bothersome tinnitus.

And, you know, I also want to preface this by saying I'm not a medical doctor.

So, I send you all out there to bring these two names to your provider, your medical provider, and have a conversation with them about what might be right for you.

And something about—maybe you could say this about people with TBI in general, but certainly with bothersome tinnitus—is they can be very drug sensitive.

They're on high alert, and the littlest thing all of a sudden, you know, their brain is—you know, there's just so much stimuli coming in, and they have to have a way to organize it all.

And, you know, things can be out of hand.

People with bothersome tinnitus tend to be very drug sensitive, so I always tell people to tell their doctor that you start low. There's no rush. You're okay. It's benign. It's tinnitus.

Now start slow and work your way up to a, you know, a clinical dose of—but no need to overwhelm your system with unnecessary side effects.

So, just walk up slowly.

Mandy: Yeah, I do see that medication sensitivity quite frequently. So, it's often a conversation that I have with my patients. What can we do non-pharmacologically to treat this? So, any other thoughts on things?

Sound as a Non-Pharmacological Tool
Dr. Gans: Yeah.

And I'm not saying medication is a first line. Remember we talked about—

Mandy: Yeah. One to 100.

Dr. Gans: I, you know, you got 99 things to try maybe before you go to—

Although it makes a lot of sense for some people.

I mean, you know, I can't tell you how many people have been like, you know, their ability to create that space—they needed a medication to bring down the fire so that they could actually create the space to actually be able to help themselves.

So, there is a place for medication. Absolutely. And it's not for everyone, but when it's for you, it is for you.

So, you know, but talking about other things is again using sound.

Sound is your friend.

And you don't have to spend money on sound. Okay? You know, anybody that has a smartphone has access to all kinds of free sound.

So, don't be in—at least until the brain can figure all of this out, you know, until tinnitus can be shifted from the bothersome to the non-bothersome category—make sure you have a very rich environment of sound around you.

Fall asleep to the sound of birds or to the sound of crickets or to your favorite symphony or to white noise or pink noise or whatever you find pleasurable.

Whatever is relaxing to your brain, turn it up. Turn up the volume, you know.

And it doesn't make tinnitus go away, but it's just cushioning your brain enough so that you can soften your grip around this benign body sensation until the brain can understand, "Oh yeah, that is just a benign body sensation that I can push into the background."

So, it's all about stress reduction and keeping yourself comfortable.

Well, it isn't all about stress reduction. It's about education.

And that can be so hard to get about tinnitus.

And that's why I'm really talking to you today because, gosh, I get patient after patient after patient, all these years, coming into me saying, "Well, my doctor told me to just go home and live with it," or, you know, "Don't come back to see me because there's nothing—I can't find anything wrong," or, you know, "Take this pill," or, you know, these are all—or "Go get an MRI."

You know, nobody likes MRIs, especially people with tinnitus. You know, it's so loud in there and it's like you're claustrophobic.

Billions of dollars are spent on extra MRIs that are not necessary.

And one of the problems with tinnitus is every doctor thinks, "Oh my God, I don't know what this is, so we better go get an MRI because maybe that'll tell us something."

Well, it usually doesn't tell you anything.

So, it's not really a good idea to be sending everybody, you know, MRI, you know, with tinnitus.

There are certain cases, maybe single-sided deafness and things like that, where you might want to just, you know, dot your I's and cross your T's.

But acoustic neuromas, you know, which is the tumor on the auditory nerve, are very, very rare and they're always benign.

Anyway, so the protocols that we have in place for our medical doctors are not always the best.

So, I hope medical doctors will watch your podcast and realize, "Oh yeah, so I need to educate my patients. I need to reassure them nothing is broken. There are many things that they can do."

They can go to MindfulTinnitusRelief.com and take a course there in their home, in the privacy of their own home, which is going to help them shift tinnitus from bothersome to non-bothersome.

And there you go.

Why Tinnitus Is So Misunderstood
Mandy: Yeah, I think that's the biggest thing.

I've had several patients come back to see me after they've kind of done the rounds. They've gone to either ENT, audiology, had some hearing testing done, and they were told everything was fine and that they didn't need to worry about their tinnitus and don't come back because there's nothing we can do for you.

And then they come back to me and I'm like, "Well, there is—there are things that you can do. Just because that particular provider didn't know doesn't mean there's nothing we can do. So, let's look for other options."

And it's hard to answer those questions when they're getting so much different responses from so many different people.

Dr. Gans: Yeah. Tinnitus is a real—maybe that's why I've become so fascinated with it.

It's such a misunderstood body sensation.

I'll explain to you why if we have a moment.

So, medical doctors—let's talk about medical doctors.

They are trained to fix things. So, they go to medical school and—and thank God. I mean, my gosh, they're, you know, my kudos to medical students.

Now, they're in medical school learning how to fix things. Kind of like a car mechanic, in a way. I don't want to bastardize, you know, denigrate their profession, but, you know, they're learning—they are there to—they learn how to fix things.

So, when you walk into a doctor's office, you come in with a credible complaint, and they give you a pill or do a procedure and you walk out and you feel better.

So, what happens when somebody with a credible complaint as tinnitus—110%—walks into your office with a credible complaint but nothing's broken?

Doctors get anxious because doctors don't like not to know. Nobody likes not to know, but definitely doctors.

And so, with no—no disparaging their work—when they get anxious, they really kind of hope you never come back, or they'll again send you off, you know, they'll throw pills at it, they'll send you off for needless procedures and such.

And so, tinnitus is a credible body event that is distressing, much like something, you know, many of these other medical things are.

However, your brain made an error.

You misunderstood your own body and created something that never should have left the subconscious into something that is the one and only focus of your consciousness.

So, nothing's broken. You just made an error.

And so, I don't want to discount this education.

The educational piece is foundational.

And so, it doesn't sound very sexy. It doesn't sound very, you know—there's, you know, it doesn't come in the form of a pill and it doesn't come in a—you can't use a scalpel.

But filling your prefrontal cortex with accurate information is the beginning of healing anybody with bothersome tinnitus.

And then you need to work on stress reduction. And so, that's where mindfulness can come in.

The Importance of Understanding the "Why"
Mandy: Yeah. And I love that because I always look for the why with my patients.

I think if they can understand the why, they can deal with things much more.

This is happening because of this, and okay, now we know what we need to do to treat it.

I'm never—I've never been one for Band-Aids. I don't like just putting a Band-Aid on it and saying, "Well, this is what we've got, so just mask it and go away."

But it's nice to have a why and a what-can-we-do-about-it.

Dr. Gans: Sure.

Where to Learn More
Mandy: Yeah. Where can people find you if they want to learn more about your technique and things like that?

Dr. Gans: Well, again, I've said it many times, but in the bottom corner here, we have MindfulTinnitusRelief.com.

And so, I encourage anybody to go to this site. There's ways to contact me through that site.

There's also free blogs. There's a blog section there where I've written very short articles that, you know, if somebody asks me a question, I say, "Well, gee, maybe I'll write the answer to that question down."

So, I've collected a bunch of different blog articles there that I think, again, are in the service of good education.

And then, you know, I encourage anybody to just jump in and start this course and start healing from home.

Mandy: Very good. Very good.

And you sent me a couple social medias. I will put all of those links on the website in the show notes so people can find those easily.

As we wrap up today, any last words of wisdom you'd like to share with our listeners?

Dr. Gans: Yes.

Go home and heal yourself.

Sometimes something feels broken and it's not, and tinnitus is definitely that case.

So, there's more right with you than wrong with you.

Mandy: The show—thank you so much for being here.

Dr. Gans: Yes. Thank you.

Mandy: Thanks for tuning in to this episode of Brain Wellness, the podcast.

If you enjoyed this episode, I encourage you to subscribe, like, leave a comment, and share it so that others can benefit.

Please also consider supporting the show by buying me a coffee. The link is in the show notes.

You can also go to www.brainwwellness.com—at brainwwellness.com—to catch the latest info and get links on all the social medias there.

See you next time.

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