Tuning the Mind's Orchestra to Filter Out Tinnitus

 

The Person Behind the Tinnitus
You know, as my introduction had stated, I've gone kind of global with my talks on tinnitus and hyperacusis and have now sat for thousands of hours with people with bothersome tinnitus. And we're going to make that distinction between bothersome and non-bothersome tinnitus.

And so, I've learned a lot. I've learned a lot and have certainly done research, but have also, in a clinical sense, sat for thousands of hours with people with bothersome tinnitus.

So, I have learned an awful lot about the person behind the tinnitus. And I think everybody should understand that. I think that clinicians certainly, because they need to know, you know, who they're speaking with, but also people need to start understanding themselves and why in the world would I fall into the bothersome category of tinnitus?

Well, we have those answers.

So, I'm really thrilled today to be here today to help kind of clarify.

Mandy: Thank you so much. And you're so right. And for someone who is, you know, has just developed tinnitus maybe, and they feel frightened, how do you usually explain tinnitus in a way that reduces their fear rather than increases it?

Dr. Gans: Right. Right. Well, you just said the operative word here: decreasing fear.

You know, tinnitus is a paper tiger. It looks scary, but it's made of paper.

And so, this is hard for us to wrap our minds around because I'm not saying for one second that tinnitus is not devastating to the person that's bothered by it. But that doesn't mean that it isn't a benign body sensation that the brain has misunderstood as important to pay attention to when, in fact, you can safely allow it to go into the background.

Bringing Down the Temperature
Mandy: There are people that come up to us and they will say, "So-and-so, or my mother or, you know, a friend has tinnitus and they're not bothered by it. Why am I so bothered by it? Is it because theirs is louder or quieter?"

What would you say to a patient that says that?

Dr. Gans: Well, you know, also kind of going back to your last question, an operative definition is important.

Humans are meaning-making creatures. When we don't understand something, we become anxious.

Okay? So, what is critical when I meet with my patient for the first time, our first hour—also the online course makes sure that this is taken care of—is we humans need to understand.

And once we understand, we can plot our path forward.

And so, at first meeting of anybody with tinnitus, whether it's somebody on the street, or it's somebody in my clinical office, or I'm talking to a group of professionals, tinnitus is a benign body sensation, again, that the brain has misunderstood as important to pay attention to when it can safely push it into the background.

Now, I often say that 15 times in an hour, but it's really important for us to bring down the temperature and understand that, yes, tinnitus is devastating for people who are bothered by it, but thank goodness—whoosh—we can bring down the temperature knowing that we are talking about a benign body sensation.

Okay?

So, again, that educational piece is critical.

And the problem that we have with tinnitus is we need to understand the link between tinnitus and fear and understand the properties of our brain.

The Mind's Telephoto Lens
Okay? The brain is, for all—I mean, it does so many wonderful things, but probably the most wonderful thing it does for us is it keeps us alive.

And it is a—when the brain picks up on something fearful, it goes whoosh and brings it into our mind's focus.

I think of the brain as kind of a telephoto lens, of sorts.

And so, when something is either feared, fascinating, or frustrating, whoosh, the lens of the mind zooms in on it.

Why? Because if there's something to fear, I better be vigilant and I better pay attention to it.

So, whoosh, the mind closes in the lens.

But then the lens gets wrapped up in a story.

The lens gets wrapped up in a, you know, "Oh no, maybe this is a brain tumor. Oh my God, does this mean I'm going to lose my hearing? No, how am I going to focus at work? Oh, I can't live like this."

So, you know, the stories—I hear them all. There's common stories, there's also unique stories, but they are stories because we are, again, talking about a benign body sensation.

But what happens is our camera lens of the mind gets wrapped up in glue. It gets wrapped up in a Gordian knot of false information.

And we all know false information is, you know, not the human—it's not our best friend.

So, what's happening is they're locking and loading on tinnitus because they're noticing it as their amygdala—we can talk a little bit more technically—has, by mistake, because when the brain is under stress, it makes errors.

Okay?

So, when we're under stress, the brain is more likely to make a mistake.

And so, when the person recognizes tinnitus for the first time, the amygdala's job is to put it in the danger category or in the benign category, where whatever the symptom is or sensation is can safely go into the background, and it goes into our subconscious, and it's there, but who cares?

So, what's happened is the amygdala made an error, and it put tinnitus into the wrong category. It put it into the danger category.

The fight-or-flight response gets triggered. The autonomic nervous system. The thalamus opens the gate, and tinnitus goes from the subconscious, where it always should have stayed, and brings it into the next level, into our level of awareness, into our conscious mind, into our prefrontal cortex here.

And so, what has happened is the gate erroneously opened, and what never should have gotten into our mind's eye is now a thing. It's now a thing.

And now we have millions and millions—and I mean, I'll speak for the United States—20 million Americans are bothered enough by their tinnitus to go to their doctor and say, "Oh my God, this could be a brain tumor. This is not good."

And so, that 20 million group is walking the streets of our country with their camera lens locked and loaded on what? On tinnitus.

And now they're stuck.

So, I jokingly call tinnitus a stuck disorder. I mean, no insurance company is going to let you bill for that, but tinnitus is ultimately a stuck disorder.

The brain has made an error, has picked up on a body sensation—we can talk about what causes tinnitus—has picked up on this body sensation, and it has brought it to the top of the triage system.

I call it kind of the number-one slot of our mind's eye when it never really should have gotten into the triage system to begin with.

And so, my work is to help people walk it back.

And if we can unravel those stories—and they are appropriate stories. I mean, I'm not saying that a person is crazy for putting tinnitus into the danger category—but what I'm saying is, "Oops, your brain made an error. It put it into the wrong category. It's okay. There's no fire. There's no alarm here. I know it feels devastating, but let's take down the fire right now and talk about how do we unravel those stories so that all of a sudden our lens gets unlocked and unloaded, and now you can open up the lens again."

Now, tinnitus might be there. I mean, again, I have no control of that. I mean, that's between the person and the powers that be.

But my question to my patients is, "Well, let me see. 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 about 100% of the time, people are like, "Well, sure. I mean, I've got a lot of benign body sensations that are going on in me that, you know, I'm not happy about them, but, you know, I just kind of keep, you know, go on with my day and I don't put them into the fear category that's connected to danger.

"So therefore, it just floats into the background. If I want to focus on it, sure, I could focus on it, but, you know, there's a million other things I'd rather focus on."

So, that's really the effective cure for tinnitus.

And I'm very carefully using that word cure because it gets misused with tinnitus, because you can't cure something that's not broken.

So, let's use our words accurately.

But I do call shifting tinnitus from the 20 million bothersome group—the bothersome category or bothersome group—into the 30 million non-bothersome group of people that experience tinnitus as the effective cure.

Because if you can go from here to here, and if you have tinnitus for the rest of your life and it doesn't bother you, then you got bigger fish to fry.

So, let's move on.

So, you know, it's a mind shift. It's, you know, it is a credible complaint that you would go to a doctor with, but the issue is, if there's nothing broken, there's nothing to fix.

This is unique. It's not to say that it isn't a body issue, of course it is, but it's in a different category than the traditional medical problems that we go to our doctor with.

And so, you know, again, the brain has made an error.

Mindfulness: Tuning the Orchestra of the Mind
And I know that you—we spoke before, and talking about mindfulness is a really free, inexpensive thing that we can do to help ourselves.

It's not—it doesn't come in the form of a pill, it doesn't come in the form of a procedure or a device.

Mindfulness meditation is one among many, I have to say, of tuning the orchestra of the mind.

Mindfulness meditation doesn't fix anything. It's simply our brain's natural way of tuning the orchestra of the brain.

I think of the brain as an orchestra.

You know, it's funny, I have a young child and she asked me one day to explain something about the brain.

So, what did I do? I went to the computer, I looked on Google for a picture of the brain, and I looked at this picture of a brain, and I was like, "Oh my gosh, you know, the occipital lobe was in purple, the parietal lobe was in green, the brain stem was in orange."

So, the auditory cortex was in red, or, you know, whatever.

It was a picture with all these different parts of the brain in sections, and I looked at it, and I was like, "God, it kind of looks like a picture of a symphony."

You know, you have all these beautiful instruments. I mean, violins and trombones and the percussion section, the flutes, all of these beautiful instruments.

And they're all sitting in different sections, and each one is a beautiful color.

But it isn't a symphony until they all play together.

And so, the human brain is kind of the same.

Each, you could argue, each section is beautiful in and of itself, but the magic doesn't happen until the brain works in symphony, in tune.

And so, you know, it helps—I find in my work making these analogies between the body and the world around us is really helpful.

Because I know people say, "Oh, cognitive behavioral therapy, mindfulness, what's the difference?"

I say, you know, at least in our first meeting, I was like, "Let's put away all those terms, and let's speak with logic."

So, when I'm speaking with somebody, I'm speaking to their prefrontal cortex, their conscious mind, the part of the brain that we're trying to fill with accurate information when it comes to tinnitus.

And I say to them kindly that, you know, if I say anything during this hour or time that we're together that doesn't feel logical, please stop me because we need to make sure we're speaking with logic.

Okay?

Mindfulness as Awareness Building
Now, again, going back to the meditation, meditation is simply awareness building.

You know, with some people that I work with, I don't even use the word meditation. I'll just say the word awareness building.

Because until we're aware of something, we can't change it. We don't know that it's happening.

Our brain is doing all these things under the hood that we don't know about.

Now, when we focus and bring awareness to where the mind is, all of a sudden we can change a reaction into a response in our lives.

I'd love to flesh out the difference between a reaction and a response to tinnitus if you have a moment.

So, Viktor Frankl was a Holocaust survivor and then he became a psychiatrist, and he wrote a wonderful book called Man's Search for Meaning.

And in that book, he was quoted as having said that between every stimulus and response is a space. And within this space lies our freedom and our choice.

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

So, when I see somebody with bothersome tinnitus—I have to clarify, bothersome tinnitus—comes to see me, they are inevitably coming into me with stimulus or tinnitus reaction, tinnitus reaction, tinnitus reaction.

There's no space.

And so, my work with them is simply to create that space so that they can start to choose their response to tinnitus.

And so, I believe that mindfulness meditation is one among many.

I'm not, you know, I'm not saying that mindfulness meditation is the second coming and this is the only way. Absolutely not.

What I love about mindfulness meditation is you can do it at 3:00 in the afternoon and you can do it at 3:00 in the morning.

You don't need a doctor's prescription. Doesn't have to cost any money.

And it's a human capacity to be able to stop and bring awareness to: Where is my mind right now?

Am I reacting through life? Am I just living my life stimulus, reaction, stimulus, reaction?

Or am I feeling a sense of agency? Like I can now start responding to life.

And now, with corrected information, once you disengage tinnitus from fear, oh my God, the number of the different ways in which you can respond to tinnitus are wide open.

Mandy: Wow, I think that's a really great way of explaining it and explaining why mindfulness works because, like you say, a lot of people, when you get tinnitus for the first time, you may read things online about CBT or mindfulness and it just doesn't connect, you know, because the logic isn't there, the logic hasn't been applied and the understanding isn't there.

And when you talked about the meaning that people associate with the noise, you know, and actually helping them, in a way, reframe their meaning or change your relationship with the sound that they're hearing from something that is a real tiger to a paper tiger, you know, trying to alleviate that fear.

Understanding that process then allows for room to help correct those signals that the brain is receiving.

Dr. Gans: Yeah, because the brain knows what to do with benign body sensations.

Okay? So, let's do a quick, a quick little exercise here.

I want everybody who's listening, you know, the whole world that's listening to our podcast right now. I want you to pay attention to the bottom of your foot.

Now I'm going to make an assumption that you're sitting down and your foot is on the floor.

Now, if you stop and pay attention to the bottom of your foot, you'll pause for a moment and notice, "Oh yeah, there's kind of a pressure, a tingling, either coolness or warmth depending on, you know, what the weather is."

But once we get the podcast going again, we're getting into this conversation, that sensation at the bottom of your foot, you wouldn't leave this time that we have together and say, "Gee, that was quite a sensation at the bottom of my foot."

The reason is because your—the brain is a prediction machine.

Okay?

And again, you need to—you've got to understand the number-one goal is for our brain to keep us alive.

And so, the brain has designed itself to become a prediction machine.

When it can predict something and it, you know, normal, boring, happens all the time, what the brain does us a favor and it says, "You know what? We're not going to put any mental energy into it. We've got a million other things. We've got this fascinating podcast to listen to.

"So, I'm going to do you a solid. I'm going to do you a favor and I'm going to take that sensation that, by the way, is happening right now and I'm going to push it way into the background."

Okay?

So, again, the brain knows naturally—that's called habituation. The brain naturally knows what to do with otherwise predictable, uninteresting, boring sensations.

It naturally puts it into the background.

Now, if you really want to spend the rest of your day focusing on the bottom of your foot, I say go at it.

But I would imagine nobody would choose to do that.

Accurate Education Comes First
Now, we have millions of people around the world that have misinformation about tinnitus, not by anybody's fault necessarily, but misinformation about tinnitus and the brain.

Whoosh, connects it to fear and all of a sudden again that lens gets locked and loaded because if it's feared, then the brain is going to put all of its energy into it.

And so, we need to walk people off the cliff.

Again, take that deep breath, and really the stress reduction piece is really critical, too.

You know, the education piece—I always talk about tinnitus care goes from 1 to 100.

Now, 1 is education, and, you know, after you've got one accurate tinnitus education, I can't—not all information is accurate, but—

So, one is accurate tinnitus education, and then, you know, then you're off to the races.

You've got 99 other choices and many more than that, of course.

But if you don't have one, you don't get past. You don't get to two, you don't get to five, you don't get to 100.

So, this is the first stop on the journey.

And once you establish that accurate education, again, you don't need to spend tons of money on tinnitus.

You don't need to go searching for that cure.

There's no pill and procedure and device and stuff like that.

You can find ways to tune your orchestra and then put what I've, you know, what you know, accurate information into play and really reteach your brain to disengage tinnitus from fear.

And then it goes where the sensation at the bottom of your foot goes. It goes into the recesses of our mind.

And so it's, you know, it's simple but not easy. That's what I always say.

This is simple but not easy.

And again, you know, I can be very blasé about tinnitus. "Ah, it's a paper tiger. Ah, it's benign. Oh, you know, no big deal."

But it is not lost on me. After sitting for thousands of hours with people with bothersome tinnitus, it is not lost on me that tinnitus can be devastating.

However, with all due respect, it's very hard for me to get excited about a benign body sensation.

When Patients Have Already Been Through the Medical System
Mandy: And it's interesting what you say there because that education really should start at that first-ever appointment that that complaint was raised.

So, whether that's with their primary doctor, GP, ENT, if they're told that there is nothing that can be done, not only are they getting inaccurate education, but two, the fear is increasing even even more there.

Can I ask when people come to see you, have they had explorations? Have they had all their diagnoses? What tends to happen in that case?

Dr. Gans: Well, I'll just share with you something that just recently happened.

I was seeing a patient for the first time and they came in and said that their audiologist gave them a list of resources for tinnitus, and one of the resources on the list was the suicide hotline.

She took a look at that and was like, "What? I have tinnitus and they're putting suicide hotline as one of the tools at my disposal. My God, should I be worried about my wanting to end my life?"

So, you know, it's—I don't know. You know, there's not a doctor out there. There's not a clinician out there that wakes up in the morning and says, "Gee, I want to mess up my patients."

That's just not on. That does not happen.

But we have to be understanding the unintended consequences of false information, or the, you know, the importance of accurate information.

And as, you know, I will stand on a mountain and scream to the hills. I want everybody to get this accurate information.

Some of the most intelligent medical doctors that I know have no idea what tinnitus is because it's baffling to the medical community because actually nothing's broken. There's nothing to fix and doctors are trained to fix things.

And again, you know, we're in a medical model, I would say, throughout the world where, you know, it's—and again, this is not through malice.

Everybody wants people to feel better.

And so, you know, traditionally when there's something bothersome, we look for a pill. We look for a procedure. We look for something to fix what's broken.

And God bless. I mean, who hasn't been to a doctor where that pill or procedure actually did the magic trick?

But you're not going to get that with tinnitus.

Now, that's not to say that there isn't a place for medication, but the thing is, the medication that would be helpful for somebody—and we could talk about anxiety because that should be the focus.

If there is anything in anybody's lens as to what to treat, it would be anxiety.

But, you know, there are pills that can be helpful, but there's nothing directly for tinnitus because there's nothing broken.

The brain has simply misunderstood a body sensation.

And, you know, there's no pill that's going to be able to fix that because there's nothing broken. There's nothing to fix.

So, I think, you know, in some cases, yes, there might be, you know, like somatosensory issues there if they've got problems with their jaw, their neck, which you would hope that they've had explored.

But very often, even sometimes treating that doesn't always guarantee that the signal goes away.

And what we tend to find, I'm sure it's the same with you, is that people spend many years searching for that root cause. And it can end up being even more problematic.

Understanding Correlation Versus Cause
Mandy: Yes, for sure. And, you know, let me take a moment because what you're saying is so, so true.

You can tell that I'm very—I want in my work to be very accurate with my words because when patients come in to see us, they hang on our words.

When I go to my medical doctor, I'm hanging on his or her words, you know.

So, you know, we need to be the experts. We are the people that people come to.

And so, I think being accurate with the word is so, so, so critical.

And so, we have to talk about, you know, what causes tinnitus?

If we don't know what causes tinnitus, and people will say, "Well, there's different perspectives."

Well, actually, there isn't.

There is one thing that causes tinnitus.

Actually, there's three. There's kind of a trifecta or a correlation that will make a person misunderstand tinnitus and bring it to their awareness.

But I just—I get so annoyed when people say, "Well, there's many perspectives on tinnitus."

It's kind of like saying, "Well, gee, there's many perspectives on an ingrown toenail."

I mean, I don't know.

Even in the name, it describes what's going on. An ingrown toenail is a toenail that's ingrown.

I don't think a bunch of doctors would sit around a table and start debating on the perspectives on an ingrown toenail.

Now, there can be many treatments. I will give you that.

Although, you know, I think we all know what to do with an ingrown toenail.

But I'm not saying that there aren't ways to manage it, but in and of itself, I don't think there's a lot of debate as to what an ingrown toenail is.

And so, my question is, well, why are we debating about what tinnitus is?

Tinnitus is one thing.

Okay?

First, we have to understand the brain.

The brain is a prediction machine and it likes things to be filled in.

It doesn't like to lose. The brain loves everything to be filled in.

For example, we all have a blind spot, and I go like this trying to find my blind spot, which I can't really.

You know, the brain knows that there is a blind spot. That's where the retina hits the back of the eye, and so we're born that way.

And so, the brain says, "Well, gee, you know, when I'm looking at this beautiful horizon, I don't really want to see a big black spot. So, I'm going to do this person a favor. I'm just going to fill it in."

So, the brain is a funny thing. It's not, you know, it does a lot of magical things under the hood that we're not even aware of.

Thank God it does some great stuff.

So, the brain loves to fill things in.

Now, the brain does not like to lose.

The Five Senses and the Search for What Is Missing
And what happens—and I like to talk about another body part or another sense. I'm going to talk about actually five senses.

We have touch, taste, smell, vision, and hearing.

Okay, so the top five. There's actually more than five, but we're going to just talk about the traditional five that most people know about.

So, when the brain—the senses are our window into the world, and believe me, the brain does not like to lose senses.

Now, you and me and anybody past a certain age is, you know, going to agree that over time there's wear and tear on the body and our senses don't get stronger.

They probably get a little—you know, our vision doesn't get better, hearing, you know, usually doesn't get better over a lifetime. I don't know if it ever does.

But anyway, so through the passage of years there's wear and tear.

I call it sometimes, you know, maybe erosion, healthy erosion, on the body.

So, let's talk about another body part to help us understand what's happening in the ears.

So, let's say somebody loses their hand.

Okay, let's say I cut my hand off.

My hand is literally here. This is where all the memories of the hand are. This is where all the sensations come to. This is where all the commands come from.

Now, if I lose this hand, God forbid, the brain says, "Wait a minute. Where's my hand? I've always had a hand. It has to be here."

So, what does the brain do?

It starts to search.

I mean, that makes sense.

So, the brain starts to search and search and search, and in that search it's getting really frustrated because the searching is not making the hand come back.

So, it searches harder and harder and then the neurological excitation of that search, boom, creates the sensation as if the hand were still there.

Now, I'm going to quickly gloss over three more of these, but when doctors report that when we—if we lose our sense of smell, people will report phantom smells in the place where their ability to olfaction, the ability to smell, was.

Taste, same thing.

We can, you know, if somebody loses their sense of taste—and I don't know about you, when I had COVID, I certainly did—you can almost—the brain likes to fill in and it creates almost a phantom taste.

Well, let's go to vision.

Vision is another great example.

There's a syndrome called Charles Bonnet syndrome, where when people lose vision because of macular degeneration, the brain starts to freak out because it's not able to see vision like it used to.

So, it starts to search for vision and boom, in that excitation creates phantom visions.

And then we have hearing, and that's why you and I are here today.

Okay?

So, when something is happening in five out of five, it makes me say to myself, "Gee, I think there's something to this."

The Cochlea and the Search for Missing Frequencies
Now, let's go to hearing.

Now, I'm speaking to an amazing audiologist and so, you know, forgive me if I say this incorrectly.

But inside our cochlea, the inner ear, we have this tiny little snail-shell organ called the cochlea.

It's kind of the last hurrah before sound goes to the auditory nerve, to the auditory cortex, and we get sound.

Well, there's—inside this cochlea, shaped like a snail shell, there are these tiny little hair cells or cilia that are in a tonotopic map.

Now, if we take the cochlea and unravel it, so imagine this cochlea is flat in front of us on the table because we've unraveled the snail shell.

Now, you have the high-frequency hair cells here and the low-frequency hair cells down here, and just like a piano, you have every hair cell in between.

Now, you roll that back up, so the low notes starting with the low notes.

So, you roll it, roll it, roll it, roll it, roll it.

The mouth of the cochlea is where the highest-frequency hair cells are, and the lowest-frequency hair cells are deep, deep, deep inside the cochlea, pretty well protected.

So, the passage of time, you know, the accumulation of birthdays, we have waves of air that are coming through the ear, and this is the erosion part.

Every human being out there starts to experience hearing loss.

Everybody, even if it's not measurable.

You know, when we're measuring hearing loss, we're going from 250 hertz to 8,000 hertz, but humans hear out to 20,000.

Okay?

So, the reason why audiologists only measure from 250 hertz to 8,000 hertz is because this is usable hearing.

They're not interested in beyond because that was almost overkill, you know, when we have almost overkill hearing beyond that point.

But you could argue even the person with what looks like perfect hearing on an audiogram, if you took it out further, it surely would start to go down, down, down, down, down as the higher frequencies go out after a certain age.

So, you could argue that all humans after a certain age have hearing loss, whether it's measurable or not, whether it's hidden hearing loss or not.

This is—there we have to all agree that, you know, that the senses dull over time, and hearing is a sense, and it dulls over time.

But, you know what? We have pretty great hearing usually, so, you know, many of us are going to go to our grave with some hearing loss and we never would know it.

So, what's happening, to get back to our analogy or our understanding of the senses, the brain says, "Wait a minute. I've—where's that—where's that sound? Where's that frequency? I've always heard it. I was born hearing it. It has to be here."

So, the brain starts to search and search and search and search and it gets really freaked out because it can't—it can't access that sound anymore, so it searches harder and harder and harder and harder and boom, that's what we call tinnitus.

Now, whether or not tinnitus stays under the hood or goes into our consciousness has a lot to do with the human being behind tinnitus.

The Tinnitus Trifecta
So, let's talk about the trifecta.

I call it the tinnitus trifecta, okay?

So, there are three things that would make somebody who has something as benign as tinnitus, the silly brain.

I also define tinnitus like this: The silly brain is searching for a sound that it's no longer able to receive.

And for some people, that becomes a traumatic search.

Other people, you know, they got bigger fish to fry, so tinnitus never comes to fruition.

So, here are the three reasons why somebody would fall into the bothersome category.

Again, this is the category I work with.

People with non-bothersome tinnitus don't come to see me because they don't care that they have tinnitus.

So, but every single person, 100% of the time that I'm working with—and anybody with bothersome tinnitus—has three things in common.

Number one, hearing loss, but we already talked about that.

Okay?

For some, you know, they need hearing aids. For others, you don't need hearing aids.

To put a hearing aid on somebody who doesn't need a hearing aid is like putting glasses on somebody who has perfectly good vision.

And they'll rip it off immediately.

So, there is a beautiful—I mean, thank God for audiologists. Thank God for hearing, you know, for people that need it.

But for people who don't need it, it's more frustrating than not.

So, anyway, we're not going to talk about hearing loss anymore.

However, this is one of the key ingredients to bothersome tinnitus.

Number two, the second ingredient is stress.

And this is—this is critical.

This is critical because when we're under stress, the brain makes errors.

And that's what we're dealing with is a brain error.

And now it's an innocent error, but it is a brain error that we have to correct.

And when we're under stress, you know, we can't respond to life, we're reacting.

So, this we do come back to quite, you know, and certainly can in this talk, but I certainly spend an awful lot of time on this with my patients.

And then number three, I say that every single person with bothersome tinnitus has an amazing personality.

Right, and I usually get a chuckle and kind of like, "Oh, you're trying to butter me up."

But actually, when I explain to you this person—this personality that everybody we work with with tinnitus has, you will realize, "Gee, that is kind of an amazing personality."

It's what makes them successful.

It's what makes them, you know, it's what their jobs love about them. It's what their loved ones love about them. It's what they love about themselves.

It's what gets them out of bed in the morning.

So, this amazing personality has an underbelly.

And it's the underbelly that's pulling them down.

And so, I don't—I'm not going to change anybody's amazing personality. We want that. We need this in the world.

So, I'm not going to touch that, but I am going to help people identify the underbelly.

Because the underbelly is keeping them stuck.

And that's why I call tinnitus, jokingly, a stuck disorder.

The "Amazing Personality"
Okay. Now, let's talk about the underbelly.

Now, and it's not really an underbelly because it is part of their amazing personality, but 100% of the time, the people that I work with with tinnitus and the people—anybody in the bothersome group, 20 million Americans—they are the kind of people who are very alert, vigilant.

They hear things, see things.

They are alive and they're showing up.

Now, if they spot a problem, they latch onto it and they have trouble letting go until they figure it out.

Okay?

So, I mean, again, I mean, who wouldn't want somebody in their lives that spots a problem, latches on, and doesn't let go until they figure it out?

But what happens when they are latching onto something that they thought was a problem when, in fact, it isn't and the brain really should have pushed it into the background?

And that's when you get the person with tinnitus becoming—using their vigilance against themselves.

So, this otherwise beautiful quality that keeps us alive—I mean, we have to be vigilant. We have to be looking for dangers in our world.

But what happens if that same vigilant person gets locked and loaded around something that never was theirs to hold and then creates a story around it, a Gordian knot, and it gets all stuck and sticky?

And then the person is walking through life like this.

Okay?

And so, this is the amazing personality, and so that's why education is key.

Okay?

So, we have tinnitus. Again, I'm using my hands a lot.

This fist is the tinnitus.

But there's a fire that's below the tinnitus.

And so, tinnitus is always going to be benign, but the fire below it is one of, I would say, anxiety.

Okay?

That fear, that connection, that vigilance is one of anxiety.

And so, you know, because tinnitus is benign, we can explain it away. We can use logic to push it to the side.

But then we have to deal with the real issue, which is people playing sharp.

The Stradivarius Analogy
Now, let me explain what I mean there.

I actually—I'm going to move my camera so you can see this violin in the background, violin in the background, but I use this as an analogy with a lot of my patients.

Okay?

So, for those out there that are musical or enjoy going to the symphony, we have what's called a Stradivarius.

Now, many of us know that this is one of—not the only, but one of—the most precious violins out there.

Now, let's imagine we took a Stradivarius and what I feel like is when I'm sitting with my patients that I'm sitting with this beautiful Stradivarius, worth millions and millions and millions of dollars.

In fact, humans, of course, are more precious than Stradivarius, but we'll use it by analogy.

So, I have this beautiful, beautiful instrument and I take the four pegs or the four strings and I crank them up really tight, really tight.

All right, and it's about to snap.

Now, I take this beautiful instrument and I start to play it and it doesn't sound very good.

Okay?

So, what do I do? Do I throw out the instrument because it doesn't sound good?

No.

I mean, that would be throwing out lots of, you know, a beautiful piece of art.

What do I do?

I simply loosen the strings.

And so, my argument is that I get to work with people who are walking around with their strings too tight.

Now, anxiety tends to be tight.

I think of a violin. If you loosen the strings too much, you know, then you're flaccid and depressed and you can't move.

But, for those that are walking around with their strings too tight, you're not going to be making very pretty music.

And so, that's again where mindfulness meditation comes in, because I really do believe that it is our human capacity, our way of helping ourselves to make sure that we're at least playing in tune.

I don't know a symphony out there that doesn't have a concertmaster that gets up in front and makes sure that all of the sections are playing in tune.

And once we're sure that everybody's playing in the key of A, boom, you know, Beethoven, you know, all this beautiful music can happen.

But imagine if the violins were playing in the key of B and the trumpets were playing in the key of A and the flutes are in F or whatever and everybody's playing in a different key.

It's cacophony.

So, when we have misinformation, the brain has the tendency to be cacophonous.

And again, in the world we're living in right now, this is resounding. We all know this now.

And so, it is our individual responsibility to tune our own orchestra.

Or nothing beautiful can come of that, right?

And so, I have the luxury or the pleasure of working with people that simply are playing a little bit sharp.

They're playing a little bit sharp.

Nobody ever died from that.

But my job is to educate them and help them find ways to consistently make sure that their orchestra—that their symphony, their violin—is in tune.

And then life happens.

But I don't know about you, when I'm playing in tune, I have more space, I have more choice and freedom to respond to whatever comes my way, even if it's really difficult or traumatic.

At least I can respond to it in helpful ways rather than these old reactions that, you know, just tie me up in a knot.

So, again, this is my push for mindfulness meditation.

Now again, there's many ways to calm the mind.

I mean, many of us love to exercise. Many of us love to eat good food. Many of us, you know, love to be with loved ones.

Many of us love to read books.

And all these things that we do are part of the symphony. They're part of our way of tuning our orchestra.

But when patients come to see me, you know, we need to go—you know, we need to help them with the stress part.

And I have found through my thousands of hours and through the MindfulTinnitusRelief.com course that I created at UCSF many years ago and is now offered throughout the world that the important mindfulness meditation piece—again, it doesn't fix tinnitus. It's not designed to fix tinnitus.

Why?

Because there's nothing broken.

But what mindfulness meditation does is it helps the brain to reduce the stress so that you can start to put into place accurate information.

So, there's often understanding about it that, you know, mindfulness is there to fix something.

But no, no, it's not designed like that.

That's like saying that tuning, you know, a tuning fork, you know, or tuning up of the orchestra is the fix.

No.

That's just the preparation for us to make music.

Mindfulness meditation is the preparation for us to live a meaningful life.

Stress Is More Than Emotional Stress
Mandy: It's interesting when you talk about stress there because I'm sure it's the same for you.

Some of our patients might come to us and say, "But I'm not stressed," you know, or "I dealt with stress well," especially this type-A personality type that you've described, you know, needing to be in control.

Maybe they've, you know, head of their family. They've dealt with stressful situations.

Why can't I deal with this?

And a lot of people think about stress as just emotional stress, what's going on in their mind, but I'm sure that's not just what you're talking about there.

Is there—there's more to it?

Dr. Gans: Yeah, Gladys, what a great question.

You know, thank you for helping me flesh this out.

I mean, that really goes to the core of something.

So, we have to start with a rule.

Stress increases tinnitus bother. Relaxation decreases tinnitus bother.

Okay?

And remember, that's our goal, is just not to be bothered by it.

That's the effective cure.

Just don't be bothered by the benign body sensation and boom, it goes into the background.

So, that rule that we have, that law, that stress increases tinnitus bother and relaxation decreases tinnitus bother, you know, then we have to talk about what does stress mean?

Well, I actually just wrote an article about this, you know.

If you go online—and you know, I'm a big fan of the internet. You know, I've gone online and I've Googled and searched all kinds of things—but tinnitus is usually not going to end well for those who Google it.

So, let's be aware that the rabbit hole of tinnitus searches is usually not going to come up positive.

All it takes is one bad piece of information to get the story wrapped and loaded around it.

So, let's go back to stress.

So, again, this article that I just wrote is, you know, there's all this confusion on the internet about, "Oh, you know, you shouldn't drink caffeine. You know, you shouldn't have too much salt."

You know, a doctor will say, "Oh, well, your tinnitus will go away if you just don't have any more caffeine."

And so, people who otherwise—I mean, I'm going to share something personal with you—I don't even want to imagine going through the day without my cup of coffee.

Okay?

Now, I don't need two cups of coffee, but if I don't have my one cup of coffee in the morning, I am very unpleasant to be around.

You know, so think about it this way.

The question is, does caffeine stress your body out or does it relax it?

All right.

Now, I have a lot of friends—and honestly, I can't relate to them at all—who get, who feel kind of a visceral stress or a visceral kind of stimulation in their body that doesn't feel good when they have a cup of coffee.

Okay?

I can't relate to them.

I love them, but I can't relate to them.

But, like for example, if you told me that I couldn't have a cup of coffee tomorrow morning, I would be stressed all day today.

Now, if I said to one of my friends, "Hey, you have to have a cup of coffee," that would be very stressful on their body.

So, if I don't have a cup of coffee, my stress—I mean, excuse me, my tinnitus—would likely be more bothersome.

For my friends, if they do have a cup of coffee, the stress of that cup of coffee on their system would make tinnitus likely more bothersome.

So, when we start to think of it in terms of that, we have to think about the individual and what is stressful and what isn't stressful.

Correlation Is Not Causation
Now, we have to remember—we—I don't know that I completely explained this very well—but when we talk about cause, something that kind of really gets to me is when people say things like, "Oh, tinnitus is caused by TMJ. Tinnitus is caused by medication, or tinnitus is caused by..."

It's correlational.

Okay? It's correlational.

What I mean by that is, for example, let's talk about TMJ.

TMJ's a great example, okay?

Nobody wants TMJ and I hope you get a good dentist or whatever to help you with it.

Okay?

But think about TMJ.

All right, TMJ is right here.

And boy, I don't know a single person on Earth that would want TMJ.

There is a major amount of stress going on right here.

And think about it.

So, with TMJ or any kind of chronic pain, neck pain, headaches, things like that, we become very kind of in this orbit right here.

And God forbid it's in our head.

I mean, God forbid it should be in our toe, but no, here it is right here.

And this can be incredibly stressful on the mind.

And we become very attuned to what is going on in our mind.

We feel the TMJ, we feel the sensations, and then shockingly, "Oh wait a minute. Wait, tinnitus. Oh my God, there's tinnitus."

Wait a minute.

So, I have TMJ and now my tinnitus is bothering me, so TMJ must cause tinnitus.

Well, yes, in a correlational sort of way, the stress of having TMJ can make tinnitus more bothersome.

You know, you have a little less space and freedom for your brain to make good choices.

So, it's about living like this rather than holding it in a different way.

So, in a very loose sort of way and a correlational sort of way, you could say that TMJ adds to the likelihood that somebody with bothersome tinnitus would be bothered by their tinnitus, but there's no causal link between TMJ and tinnitus.

The, you know, you have to lose hearing in order to search for the sound that you're missing.

And then if the amygdala gets in—go and on the part of it and hits the autonomic nervous system, yeah, you run the risk of the thalamus opening the gate and tinnitus going into consciousness.

So, it's messy.

I want to say it's messy, but humans like things when they're neat and clean.

So, when something else is going on, we're like, "Aha, it is caused by this."

And doctors do it too, because my God, correlation is tough.

Because that means that there's multiple things going on.

And so, going back to what you're saying is we're making a lot of bad causal links to what is causing tinnitus.

And that's—I mean, it's terribly annoying for me to hear them.

I see them all over the internet.

"This causes tinnitus. This causes tinnitus."

Well, no.

You have to lose something in order to search for it.

That's the seed that starts tinnitus.

That's also the seed that starts Charles Bonnet syndrome.

When we lose vision, the brain—we have to lose vision in order to search for vision.

You have to lose taste in order to search for taste.

You have to lose smell in order to search for smell.

You have to lose a hand in order to search for the hand.

So, it just, you know, it's the brain panicking unnecessarily.

And so, what we want to do is bring the fire down and stop with all these false causal links.

And talk about the correlation.

Say, "Yes, TMJ, you need to work on TMJ. You need to get the help that you can so that you can reduce stress and start to see the world in a clearer way."

So, TMJ's another example.

Headaches.

People say headaches cause tinnitus.

No, but the stress of having a headache will certainly make you pay attention to tinnitus.

You know, well, you know, people who experience cancer—I mean, you know, thank God for modern medicine.

I mean, nobody would argue with me here.

Thank God for modern medicine when it comes to cancer.

I mean, you know, people are living in amazing ways.

And so, somebody who has just battled cancer will come in to me and say, "Oh my God, you know, here I just got through the war with cancer and now I've got this tinnitus and it—and now I don't even want to live. It's driving me crazy."

And so, what happens with a person who's going through something so traumatic as cancer is they become very focused on their body.

The doctors are asking, "Well, how do you feel now? How do you feel now?"

Their friends and people that love them and they're even asking themselves, "Well, gee, I just took this medication. How does my body feel now?"

And so, at these times of high stress and high vigilance, we are more likely to make an error.

We are more likely to pick up on tinnitus and be like, "Oh my God, wait, maybe I have a brain tumor."

You know, somebody who's just been through cancer has been through trauma after trauma, you know, after trauma after trauma.

And so, they are more vigilant about their body than they ever wanted to be.

And so, something like—they run the risk of picking up on tinnitus, taking a benign body sensation and making it into a mountain—not, you know, mountain of molehill or whatever the saying is.

And there goes the suffering.

And so, I guess you could argue that my job is simply to help people suffer less.

And that is—that is something we all can do for ourselves.

And so, that's where the real—that's where the real bang for the buck is.

Pain Is Inevitable, Suffering Is Optional
Mandy: I completely agree. I love that statement that you just made there, suffer less, because, you know, pain will exist in life, won't it?

Pain exists.

But it's the suffering, that's where we, you know, that especially with that mindful awareness, that building awareness that you described, that's where we can now start to separate the stimulus from the response.

You know, in that space that you described so beautifully, that's where we can start to reduce the suffering that we experience.

Dr. Gans: I don't know if you know this, Gladys, but you just quoted the Buddha.

Mandy: Yes, I know.

Dr. Gans: [laughter]

Well, of course you know, because, my God, you did it perfectly.

"Pain in life is inevitable. Suffering is optional."

Now, we all have pain and I'm not going to talk about all my pains. I mean, because we all have them and my God, we don't have enough time, right?

Pain in life is inevitable. That's part and parcel of this human existence we have.

Pain in life is inevitable.

But how we suffer with that pain is largely up to us.

And so, we are simply trying to help people with tinnitus suffer less.

Disengage tinnitus from fear and all of a sudden, you're not suffering.

So.

Mandy: Yeah, similar to what I do as well with patients.

And I know naturally a lot of people, especially people listening in, it's the answers. They want the answers. They want to get the diagnosis.

And yes, if they were diagnosed with TMJ, absolutely, let's do something about that.

If they were diagnosed with menopause, for example, again, a stressor on the body there, you know, and they become a lot more aware of their symptoms.

There's 70-odd symptoms that you can get when you're perimenopausal.

Of course, you're going to be more aware, more anxious. It's a stressor on the body.

Tinnitus can occur as well.

Let's do something about that.

But ultimately, it's the relationship with the tinnitus signal that also needs to be addressed.

We can't just focus on the symptom itself.

We've got to have a holistic approach here and talk about the reaction, the response to the signal itself.

Dr. Gans: Yeah, and Gladys, it's funny you bring up menopause because I remember just, you know, I'm constantly looking at the tinnitus headlines and rolling my eyes often.

Not always, but often.

And the article that I was reading that was saying that menopause causes tinnitus.

Well, that's unfair to say because it doesn't—I mean, it doesn't really describe, you know, menopause symptoms for women are incredibly stressful on their body.

It's a natural process.

There's nothing—there's nothing weird about menopause. It's a developmental stage in the human existence.

But if you say that menopause causes tinnitus, well, gosh, you're going to get a bunch of women with menopause thinking, "Oh my God, menopause is going to cause these problems."

Well, no.

The stress of menopause, and I will give you that menopause is very stressful on the body, runs the risk of making something like tinnitus if you have the three things.

You have to always have to have these three ingredients.

If you have some hearing loss, which everybody does by the time they hit menopause, stress, which menopause certainly is, and then a vigilance.

And then, you know, this is the correlation. This is the perfect storm.

But if you read a headline that says simplistically, "Menopause causes tinnitus," it's a—you know, it pulls more eyes to the article.

I mean, maybe because it, you know, because, you know, we're looking—you know, it makes you more fearful, but is it accurate?

No.

It's—well, it's inaccurate in its lack of really flushing out what's really going on, which menopause is stressful.

And so, tinnitus is likely more bothersome.

The First Step Toward Mindfulness
Mandy: Yeah, completely.

I think there's a lot of fear-mongering out there, isn't there?

And I find that we spend a lot of time dispelling that fear and actually teaching patients how to build that awareness and access accurate information.

I mean, if there was one tool or one strategy, maybe, to teach patients or a listener listening to this episode, how to build that awareness, how do I take that step?

What's the first step to becoming more mindful?

Dr. Gans: Yes.

It's a human capacity.

The first step is being more mindful.

Nobody has to be taught how to be mindful.

It is a human capacity.

We have to be reminded to be more mindful.

I'll give you that.

But this isn't a skill that happens out there that I have to go get.

This is not a skill that I have to buy.

This is an internal—I mean, anybody—I mean, that we've had focused prayer, just focused awareness is a human capacity, and you could throw—you could put a word like mindfulness on it or meditation on it, but that's essentially what it is: bringing awareness to where is my mind right now?

And with that information, we can start making choices as to how to best help ourselves or suffer less throughout the day.

Now, it doesn't have to, you know, I'm not telling anybody they have to sit on a mat in the yogi position and meditate for hours a day.

No.

Even a five-minute breathing exercise is—you know, I would never sit down to play guitar with a bunch of friends.

I mean, it would be rude of me to sit down with my guitar with a bunch of friends and not tune up my guitar before I sat down.

That would just—I mean, they'd look at me and they wouldn't invite me back.

It would just be plain rude.

So, wouldn't you argue that it's a little bit rude or a little bit unfortunate for us to leave the house in the morning without doing even a five-minute breathing exercise?

Now, there are many apps out there that can guide us through meditation because I think we've lost our way.

And it's not to say we don't have the capacity, but oftentimes the rush of the world, the speed at which we're living, we can lose touch with our innate abilities.

So, there are a lot of apps out there.

You know, again, the MindfulTinnitusRelief.com course, an eight-week course, kind of gets us started off on a mindfulness meditation journey that's specific to the person with tinnitus.

Okay?

But it's, you know, it can be helpful to have a teacher, so to speak.

But, for not one, can we not all sit for a moment and focus in on a benign body sensation like the breath?

And then watch, where does our mind go?

Here we are focusing on the breath.

Sounds really easy, right?

Simple, but not easy.

So, we focus on the breath and then all of a sudden the mind will go off to our grocery list or to, you know, "Gee, you know, I better make another doctor's appointment to get an MRI to see, you know, about tinnitus," or, you know, something stressful going on at work, or something that they did that they shouldn't have done, or whatever.

And then we notice where the mind has gone, but then we say, "I'm not going there right now. I'm going to let it go and I'm going to come right back to the benign sensation of the breath."

And then invariably, because the mind is designed to do this, it pops off again.

That's the way the brain is designed, by the way.

And so, what happens is when we start to bring awareness to where my mind is, like I might say, "Gee, I didn't realize I was so obsessed with my grocery list."

You know, and so throughout the day I can say, "Yeah, whenever I think about, wait, what if I forget something on the grocery list?"

I could say, "No, no, no, no. That's just your silly mind kind of, you know, going to crazy places. Let me push that to the side. I'm okay. And I will get everything I need on my grocery list."

And that's obviously the most benign of all.

But this applies to tinnitus.

If we are having inaccurate thoughts about tinnitus, we better be aware of it.

Because with that awareness we can say, "I'm not going there. Not going to do it."

And we can use our prefrontal cortex to chill out the amygdala which is under the hood.

It's nobody's fault.

You know, this is happening before the brain is even aware of it, but we can use our conscious mind to chill out the amygdala that is, you know, really going on alert and say, "You know what? I just listened to that wonderful conversation between Gladys and Jennifer and now I know that tinnitus is a benign body sensation and I don't have to like it. Nobody likes tinnitus.

"But I don't have to be as reactive to it.

"And so maybe I can ask myself, okay, tinnitus is here. How can I help myself in this moment?"

That's always a really, really wealthy question right there.

That's a rich question.

I have, you know, tinnitus is bothersome in this moment, but how can I help myself in this moment?

Maybe I can take a shower because people with tinnitus love, you know, the sensation of a shower if this is happening in the morning.

Maybe I can have a cup of coffee.

Maybe I can make sure I don't have a cup of coffee.

Maybe I can eat a healthy meal.

Maybe I can call a friend.

Maybe I can go for a walk.

Maybe I can watch that video with Jennifer and Gladys so that I can get accurate information into my prefrontal cortex.

I mean, there's hundreds of things that you can do.

And so, you know, this mindfulness meditation or meditation in any of its forms is really, again, it's not fixing anything, but it's making sure we're showing up to the concert at least having tuned our instrument.

Who could argue with that?

Mandy: Absolutely.

As you're speaking there, it makes me think, you know, it's a state of being as opposed to sort of doing.

And what you said there as well, that question, asking yourself, "What can I do to help myself right now?"

That is powerful.

And that's something we can all ask.

It just creates that space between hearing the sound and the panic.

It could be hearing the sound, "What can I do to help myself right now?" and changing the level of suffering that we experience.

So, Jennifer, this conversation has been incredible.

Dr. Gans: Yeah.

Mandy: If every patient living with tinnitus could understand one psychological principle early on, what would you want it to be?

Dr. Gans: Tune your instrument.

The, again, the psychological principle: tune your instrument.

And I want to say to everybody with bothersome tinnitus, keep your eye on anxiety.

Now, anxiety is not a bad thing.

I, you know, it's maybe we're getting linguistic here, but you want enough anxiety to get to work on time.

But you don't want so much anxiety that you can't get out of bed in the morning.

And so, what we're talking about is finding that beautiful balance.

Now, people with bothersome tinnitus have to keep their eye on excessive anxiety, walking around with their strings too tight, playing sharp in the world.

Now, they've also used it to help them through life.

These people tend to be very successful.

They don't miss much.

I mean, you know, I want my—I want my accountant to have a little bit of, you know, to have enough anxiety or even a little OCD to not make mistakes.

You know, they check and, you know, if they make a mistake, they go back and they correct it.

You know, so this is also, again, this is that amazing personality that is also celebrated.

But, I would hope for everybody with bothersome tinnitus that they can move tinnitus to the side and start to look at the real issue, which is the management of anxiety.

Closing Thoughts
Mandy: Thank you so much. Thank you.

And if anybody listening wants to find out more about your program or get in touch with you, what's the best way?

Dr. Gans: MindfulTinnitusRelief.com.

And that is an eight-week course that also has my contact information, so you're always welcome to.

It also has a blog section that anybody for free can come and read—very short articles. They're not long articles on different topics related to tinnitus.

And for those who would like to embark on a mindfulness meditation approach, you know, again, the course touches on three areas.

It helps people to feel less anxious around tinnitus.

It makes sure that the person is an expert in tinnitus. That's the educational piece.

But then it starts them off on a mindfulness meditation path to tune the orchestra, to work on the stress part.

So, anybody that is interested can get in touch with me through this course, MindfulTinnitusRelief.com, and start working on these three incredibly important aspects of tinnitus care.

Mandy: Fantastic. Thank you so much, Dr. Gans.

I will put that all in the show notes so that anybody who is interested can get in touch.

And I just—I can't thank you enough. It's been a brilliant conversation, really informative.

Um, and yes, thank you so much.