Mindfulness: Re-Balancing the Brain for Tinnitus, Hyperacusis, & Misophonia Relief



An Interview with Dr. Jennifer Gans

Author: Brian Taylor, Au.D.

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

Jennifer Gans: While the practice of mindfulness meditation has its origins in Buddhism dating back as far as 2500 years, meditation is actually a natural human capacity and can be found across many religions across many cultures throughout history. The practices taught in present-day mindfulness-based approaches to medical conditions and well-being as discussed below are of a secular nature and do not require any religious beliefs, practices, or lifestyle changes other than practicing daily mindfulness meditation.

I see mindfulness as the skill of keeping sensation, emotions, and thoughts in moment-to-moment awareness without clinging to the habitual (and often unfounded) judgments that our mind tends to create. An important principle of mindfulness is that sensations, thoughts, or feelings, be they perceived as pleasant, unpleasant, or neutral, are not actively ignored or avoided. Instead, there is a relaxation of efforts at control, a tolerance for whatever discomfort arises as a temporary and passing momentary experience, a purposeful maintaining of attention on the present, an allowing of feelings to be just as they are, while observing experience with openness, curiosity, and acceptance.

The practice of mindfulness trains the mind to be with whatever sensations, thoughts, and feelings arise without becoming too attached to whatever is perceived. Those of us working with people with sound sensitivities in our practice know that this is particularly relevant for the person experiencing bothersome tinnitus. The person with chronic bothersome tinnitus rarely experiences the unpleasant sensation of tinnitus in isolation. Almost always, the tinnitus sensation is wrapped tightly in a cascade of thoughts, judgments, memories, fears, emotions, sadness, regrets, beliefs, and feelings about past, present, and future experiences living with this chronic symptom. Tinnitus gets wrapped in a Gordian Knot of our mind’s own creation and all roads to habituation are blocked (habituation will be discussed in more depth later in this interview).

Bringing awareness to how we may, in fact, be helping to create our own suffering—our own Gordian Knot—is not an easy task. Much like going to the gym to build a muscle, a personal trainer can guide us, but ultimately we have to do the heavy lifting to reach desired results. However, with a mindfulness practice, we can train our minds, rewire old thinking habits, modify our behaviors and reactions, and ultimately, learn to live with tinnitus with greater ease.

The widespread acceptance of mindfulness in modern life, as an approach to healing, stems from clinical trials demonstrating its effectiveness for a range of illnesses. It has been applied with success to a growing number of conditions including chronic pain, depression, anxiety, sleep difficulty, stress, fibromyalgia, disordered eating, chronic fatigue, psoriasis, symptoms associated with cancer, and the list goes on and on. Clinical trials suggest a positive shift in “whole-person health” with changes in relaxation, cognition, biology, and behavior. The focus of my work has been on making mindfulness accessible to the field of audiology to re-balance the brain for tinnitus, hyperacusis, and misophonia relief.

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

Jennifer Gans: What is happening inside the brain of the person who practices mindfulness is a hot topic in research these days. With new technologies in brain imaging techniques, we are able to see changes in the brain like never before. Compelling studies support the argument that mindfulness can lead to more adaptive changes in the brain as a person responds to old and new stimuli. One example is research conducted by Sara Lazar and her colleagues at Harvard suggesting that meditation leads to cortical growth and thickening in parts of the brain associated with focal attention, fear, and emotion regulation. The study revealed that experienced meditators versus non-meditators were more effective in sending information to unconscious areas of the brain, areas that exert influence on our ability to calm ourselves down when we might have an over-reaction of fear to a benign event or body sensation, as is the case with tinnitus.

Neuroimaging findings support the Hebbian theory: “Neurons that fire together wire together.” I emphasize that it is the very ‘awareness’ that shines the light on maladaptive thinking habits and behaviors giving us more conscious control to choose more adaptive choices. When we practice bringing awareness to our thoughts and actions (ie, regular yoga and meditation), we can strengthen connections within the brain. These connections facilitate better opportunity and more space as to how we choose to respond to our experience with tinnitus. Such practice contributes to creating new tinnitus neural networks, ones that can help to keep the brain in balance. Clearing the way for the natural process of habituation to take place is the result.

Brian Taylor: Tinnitus is a debilitating condition for many adults. Millions of Americans suffer from it. What is happening inside the brain of someone suffering from tinnitus and how does a mindfulness-based approach address the problem differently than, say, conventional tinnitus maskers that some audiologists prescribe?

Jennifer Gans: First let me emphasize, that the best tinnitus management approach is a broad tinnitus management approach. As a psychologist and specialist with sound sensitivity disorders a major focus of my work is on the psychological underpinnings of such disorders such as the depression, anxiety, sleep difficulty, and concentration problems blocking well-being. That said, I fully see the necessity for good audiological care as an important part of the management picture. Mindfulness-based approaches address the problem of tinnitus with (rather than as a replacement for) conventional tinnitus sound generators and there are many other tools that can be used in concert to reduce stress and promote healing. For example, while practicing any mindfulness or meditation approach I always encourage patients to use sound therapy if that helps them to relax, ease tension and discomfort.

To the question of what is happening inside the tinnitus brain, I think that Josef Rachecker, PhD of Georgetown University said it best in a recent article when he describes the generation of tinnitus as a “dysfunctional valuation process and abnormal assignment of negative meaning to a neutral stimulus” (Rachecker et al 2015). What is meant here is that the brain’s misappraisal of the tinnitus (and hyperacusis) sensation as a threat rather than as a benign body sensation is linked to imbalances in the brain’s threat appraisal system. We know through science and experience that tinnitus—in and of itself—is not a cause for alarm and can safely be habituated. The question then is, how might we reassure ourselves of this, and assist the brain in choosing the more accurate and adaptive response?

The 8-week Mindfulness Based Tinnitus Stress Reduction (MBTSR) skill-building program developed and researched with my colleagues at UCSF, teaches a meditation practice as a mental calisthenics of sorts. The awareness building practice of meditation is a way of exercising and re-wiring the brain’s learned, yet unhelpful, tinnitus reaction in exchange for more emotional balance and an adaptive response as to how we choose to relate to the sensation. This very process helps to clear the way for the brain to do what it likes to do naturally, habituate to the bothersome sound.

MBTSR and brain training. A central goal of the 8-week MBTSR program is to help participants train the brain to convince the fast-acting and mis-appraising amygdala (a structure within the Limbic System of the midbrain that is associated with the fear response) that keeping tinnitus in our awareness is a waste of our energy and resources. Like the sound of a white noise machine or fan, tinnitus also can safely recede into the recesses of our mind.

Convincing the amygdala of this fact is the job of the higher developed areas of the brain. The pre-frontal cortex conducts our executive functioning tasks, including judgment, reasoning, emotional regulation, bringing awareness to certain things, and fear modulation, to name a few. This conscious part of the brain can be enlisted to exert more control. With awareness there is a slowing down of the habitual knee-jerk reaction, bringing awareness to certain processes such as an overactive fear reaction “chilling out” the over-firing amygdala.

The pre-frontal cortex is slightly slower in processing than the amygdala. This partly explains why our brains tend to place sounds in the “better-safe-than-sorry” danger category. Research in brain anatomy and physiology shows that, when directed, the pre-frontal cortex sends fibers to the overactive amygdala. These fibers are the down-regulating neuropeptides, such as GABA, that serve to “calm down” this area so that we can use reasoning to put tinnitus in the benign category, where it belongs.

Mindfulness: The Personal Trainer of the Pre-Frontal Cortex. A mindfulness-based approach, and the 8-week MBTSR course specifically, builds these new neural networks or “mental muscles”. Because many people have lived with bothersome tinnitus for years or decades, there are a lot of familiar patterns that they feel are impossible to overcome. However, with diligent practice, MBTSR teaches step-by-step skills needed to help the thinking brain more accurately determine real threats, and to calm “knee-jerk” reactions to bothersome tinnitus/hyperacusis.

A mindfulness approach to tinnitus helps extinguish the automatic fear reaction and replaces it with a letting go of attention and perception of tinnitus. The MBTSR program focuses on helping people uncover their own internal resources toward a reinterpretation of tinnitus. With practice, people with tinnitus are capable of “More Firing, More Wiring”: strengthening connections in the pre-frontal cortex for a greater, more measured, balance in daily life. This is an important step towards unraveling the Gordian Knot of tinnitus. A quick Internet search for Mindfulness & The Tinnitus Gordian Knot will locate an in depth description of what is happening inside the tinnitus brain, and how a mindfulness practice can help transform "bothersome" tinnitus into "non-bothersome."

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

Jennifer Gans: Research into mindfulness as a management tool for sound sensitivity disorders like tinnitus, hyperacusis, and misophonia, is a growing field with well-designed studies being conducted as we speak. Expect to see a lot more findings in the months ahead. Results from the initial study conducted on the 8-week Mindfulness Based Tinnitus Stress Reduction (MBTSR) course developed and researched at UCSF showed a reduction in tinnitus bother, decrease in depression and anxiety scores, an increase in overall quality of life and mindfulness in participants. Even more exciting were the results of the 12-month follow-up study that showed that tinnitus bother continued to decrease even further when participants were re-tested 12-months after the study was completed. This speaks to the long-term potential effects of a mindfulness-based approach. These results echo numerous findings of mindfulness-based approaches and there is a study underway at Idaho State University comparing the effects of the MBTSR in-person group program with MindfulTinnitusRelief.com, the 8-week online version. I have listed links to published research at the end of this article for further inquiry.

In my experience, anyone who is bothered by tinnitus can benefit from a mindfulness approach, but who benefits the most is a pressing research question that I hope to have answered in the near future. For a provider to be able to pinpoint what population may see the most benefit will help with making skillful recommendations to patients and program offerings. What I have found in my own practice is that some people prefer participating in an in-person MBTSR 8-week course but others prefer to take the course in the privacy of their own homes (or wherever they have internet connection) using the MindfulTinnitusRelief.com online version. The online version is also well suited for the patient who lives in remote areas where tinnitus care is unavailable or for those who have transportation issues. So many of us have busy travel lives and the online course is a low-cost option, can be taken at any convenient time and goes with the participant anywhere they are.

In comparison to other tinnitus counseling approaches, the MBTSR program is relatively brief and many patients begin to see change in just days. The reason why the course is a full 8-weeks in length is that learning theory tells us that it takes, on average, about 8-weeks to really learn any new skill. We all wish there was a magic pill or safe and reliable procedure that could relieve tinnitus bother in just one fell swoop. But until that pill or procedure is developed, the MBTSR and MindfulTinnitusRelief.com course with its combination of mindfulness lessons, meditation practice, tinnitus education, gentle yoga, and various activities included in the course, in just 8-weeks people are well on the path to healing.

I recently received a message from a woman taking the MindfulTinnitusRelief.com course and she said, “After just 3-weeks of the course, I am noticing that my tinnitus is not bothering me as much. AND I’m getting along better with my husband!!” This was music to my ears because it speaks to how bringing a mindfulness approach to any and all areas of life (to whatever moment we are in) whether we are struggling with tinnitus or a relationship or any number of life-pains, approaching the moment with curiosity, openness, acceptance, and compassion for ourselves and others (all of which are a necessary component to living mindfully) we begin to live life with greater ease and joy. What we find is that people begin the course bothered by tinnitus and in no time, begin to change their perspective on tinnitus as well as all of the inevitable pains that are part-and-parcel of living.

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

Jennifer Gans: Two things that we know for certain about tinnitus (and hyperacusis) is that stress increases tinnitus bother and relaxation decreases tinnitus bother. Studies conducted with 8-week Mindfulness-Based programs have shown evidence of a decrease in cortisol levels in subjects. Cortisol is a hormone excreted by the adrenal gland in response to stress. While it can be life-saving in short bursts when threat exists, it can also act as a poison to body tissue and brain functioning when it is left to circulate in the system when no real danger is present. This excess of cortisol circulating in the organs and brain tissue of the person with tinnitus can lead to breakdown in key brain areas needed for appraising tinnitus more accurately.

Awareness of our brain’s habitual mis-appraisal of the tinnitus sound stimulus is the tool that we use to slow down an automatic knee-jerk reaction. Awareness gives us time to pause, and make space for planning and executing a more appropriate response to whatever we are faced with in the moment.

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

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

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

Jennifer Gans: Habituation is a form of learning in which an organism decreases or stops responding to a stimulus after repeated presentations. In the case of tinnitus, the person learns to stop responding to the sound, as it is categorized as no longer biologically relevant. Under normal conditions, the body naturally wants to habituate. So, when a person is faced with bothersome tinnitus (and hyperacusis), my question is always, “What is blocking habituation?” Is it fear? Is it a block due to the brain’s misinterpretation or mis-appraisal of the benign, albeit incredibly bothersome, sound?

Questions as to how to re-balance the brain for an accurate appraisal of potential threat is one that has remained a challenge for the scientific and clinical community. Drugs, techniques, and surgeries to correct misappraisal remains elusive with inconsistent relief and variable results.

Mindfulness is a proven process for rebalancing the brain. With the clear mind, that results from a meditation practice the person with bothersome tinnitus is presented with the opportunity to re-perceive tinnitus/hyperacusis for what it really is, a neutral stimulus causing no imminent bodily harm, and therefore the gates to habituation are opened to healing.

Brian Taylor: I have heard that the 8-week Mindfulness Based Tinnitus Stress Reduction (MBTSR) course is now available to be taken as an identical online class. Can you tell us how you came up with the MindfulTinnitusRelief.com online version?

Jennifer Gans: After completing the MBTSR research at UCSF and witnessing the beneficial results, I began to search for ways to share the 8-week MBTSR course with people all over the world struggling with tinnitus/hyperacusis. That’s when I began work on the online version of the course, MindfulTinnitusRelief.com, that has now been available since its launch in March 2014. Since that time, hundreds of people have taken the course all over the world.

The MindfulTinnitusRelief.com online program is led by me in a structured context with weekly lessons ~1.5 hours long (completed at a time of the participant’s choosing). On each day between weekly lessons, participants are instructed to practice mindfulness meditation exercises daily for ~30 minutes guided by audio/video recordings and one full-day (6 hour) silent retreat called the “Day of Mindfulness” held between the 6th and 7th weeks of the course. Each weekly lesson consists of instruction in and practice of mindfulness meditation as it relates to the symptoms of tinnitus and hyperacusis utilizing video/audio recordings, written material, activities, and exercises geared towards mindfulness skill development, tinnitus education, and meditation practice. Meditation exercises include mindful body scanning, sound and tinnitus awareness, sitting meditation, walking meditation, and mindful movement through gentle yoga practice. The program is demanding and requires discipline and practice. The online application of the MBTSR program has made a mindfulness-based approach much easier, convenient, affordable, and more accessible for those patients motivated to find relief.

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

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

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

Audiologists have found it helpful to refer their tinnitus/hyperacusis patients directly to the MindfulTinnitusRelief.com website to complete on their own in between their audiology visits. As mentioned earlier, using a combination of devices such as sound generators in conjunction with a mindfulness-based course is most helpful in shifting tinnitus/hyperacusis from a “bothersome” to a “non-bothersome” sensation. During appointments, audiologists can provide the evaluative and rehabilitative services that they are best suited to provide. By then referring their patients to the MindfulTinnitusRelief.com course to complete at home on their own, professionals have commented that the 8-week online MindfulTinnitusRelief.com has empowered people with tinnitus/hyperacusis to put healing back into the hands of the patient, where it largely belongs. This takes the undue pressure off of the audiologist to solve the tinnitus puzzle for their patients during their visits.

Unfortunately at this time, third-party payers are not reimbursing for the course but I have kept the cost relatively low at $325 for the full 8-week program. Agencies supporting the victims of the Boston Marathon bombings and the Musician’s Clinic of New Orleans have free use of the course for their patients and I am currently working with agencies like the VA to make the course readily available to Veterans.

The MindfulTinnitusRelief.com online program has a strong support network for professionals wanting to learn more about mindfulness as an approach to sound sensitivity disorders through a weekly blog published at MBTSRBlog.com, frequently updated resources listed on the website, MindfulTinnitusRelief.com, and through direct contact with the MBTSR program at jg@mindfultinnitusrelief.com.

Brian Taylor: If audiologists want to learn more about MBTSR and MindfulTinnitusRelief.com how might they do that?

Jennifer Gans: There are several easy ways to learn about MBTSR and MindfulTinnitusRelief.com including a free 3-week trial of the program for audiologists and professionals. I can be contacted at jg@MindfulTinnitusRelief.com to start you with the Free Trial and am happy to answer any questions that readers may have.    
Jennifer Gans, Psy.D., is the Founder and CEO of MindfulTinnitusRelief.com. She is a San Francisco-based clinical psychologist specializing in the psychological impact of deafness, tinnitus, and hearing on well-being. Dr. Gans is a psychologist consultant at the University of California, San Francisco (UCSF) and researcher at the VA of Northern California.
References
Gans JJ, O’Sullivan P, Bircheff V. Mindfulness based tinnitus stress reduction pilot study. Mindfulness. 2013;5(3)[June]:322-333.

Gans JJ, Cole MA, Greenberg B. Sustained benefit of mindfulness based tinnitus stress reduction (MBTSR) in adults with chronic tinnitus: A pilot study. Mindfulness. 2015. 6 (5)[October]:1232-1234.

Lazar SW et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17)[Nov 28]:1893-1897.

Rauschecker, Josef P. et al. Frontostriatal gating of tinnitus and chronic pain. Trends in Cognitive Sciences. 2015; 19(10): 567 – 578.

Gans, J. Mindfulness Based Tinnitus Stress Reduction: Unraveling the Gordian Knot of Tinnitus. Hearing Review. 2015;22(7):28.