Awareness Building Toward Changing our Perception of Tinnitus

Author: Jennifer J. Gans, Psy.D.

Awareness: Discovering, Building, Choosing

Some 50 million people in the United States and approximately 240 million people worldwide have experienced tinnitus. Despite many “snake-oil” solutions that are pervasive, especially on the Internet, the hard truth is that currently there is no cure for tinnitus. There are, however, a number of tools available that can—and do—teach people skills to reduce the symptoms of tinnitus.

Fueled by years of keen interest and research into the intersection between mindfulness and tinnitus, I developed the Mindfulness Based Tinnitus Stress Reduction (MBTSR) program, an eightweek online program focusing on reframing people’s experience with tinnitus. This includes elements of deep breathing, yoga, relaxation, and awareness building.

Awareness building (sometimes called “meditation”) is the core skill taught in the MBTSR Program. MBTSR approaches this by having participants practice awareness building in a calm, quiet, and comfortable place. We focus on the breath as the point of focus: landing awareness on the place in the body where they most feel the breath—maybe the wave of air in the nostrils, maybe where the belly rises and falls. We caution them not to be surprised or discouraged if the mind shifts to other sensations, thoughts, or even emotions; that is just what our minds are prone to do.

An example of an awareness building exercise is the noticing of when the mind has left a pre-designated point of focus, such as the breath. When we notice that the mind has left this point of focus, we become aware, when we wake up to the moment. After noting where the mind has gone—with curiosity, openness, acceptance, and self-compassion—we simply replace our focus back on the breath. Again: the mind may wander off to the sensation of tinnitus (or thoughts about tinnitus), and at the moment when they notice their mind has left the breath, we ask them to note where their mind has gone, and then, with gentle compassion, return their attention to rest lightly on the breath.

This may sound simple, but it is far from easy. Yet with consistent practice, the drifting of thoughts and bringing awareness back to where they choose begins to come more naturally. Participants may then feel ready to begin to take this approach into their day-to-day experiences, applying it during seemingly mundane chores, like brushing their teeth and doing the dishes. In time, they begin to apply this practice during encounters with others—with people they know, with strangers, at the bank and at the grocery store, at the movies, at home reading a book or watching television, having a conversation. With consistent and diligent practice, their “strength” builds in bringing their intentional focus where they choose their focus to go.

This is a skill to be practiced over a lifetime. Even when we become “seasoned” at using our internal resources to heighten this awareness, we will need to practice consistently. Yes, it is much like going to the gym; I encourage participants to approach awareness like a muscle being exercised. And recent research uncovers evidence that we can—and do—strengthen the brain with such exercise.
Conditioning the Brain to Better Handle Stimulus Response

In the human brain lies the limbic system, composed of an exceedingly complex set of structures that supports many of our functions, including the landscape of our emotional lives.

Within the limbic system is the amygdala, a collection of almond-shaped nuclei, whose function includes being the first part of brain to evaluate incoming stimuli and determine if that stimuli 1) is a danger and needs our full attention, or 2) poses no danger and can be safely ignored.

This decision is made unconsciously before we have the chance to reason and decide if, in fact, the stimuli truly pose a danger. To a large degree, this part of the brain is informed by the saying, “Better safe than sorry.” This snap judgment is made before we even have the chance to give the stimuli any conscious thought.

And so it is with auditory information: we take in sounds that then travel to the amygdala to be evaluated and either monitored further as a possible threat or pushed to the recesses.
Making Decisions

For those with tinnitus, it’s believed that the amygdala is having trouble deciding, and so the sound just stays in the person’s awareness, which is why we often focus so intently on that sound, trying to determine whether it’s a danger.

This misappraisal of threat by the amygdala may be the very reason why some people seem to experience bothersome tinnitus and some do not. Most (perhaps all) cases of tinnitus begin with some degree of hearing loss, but not all people with hearing loss have tinnitus. This has puzzled scientists for years.

I propose that that the difference between those who experience bothersome tinnitus, and those who don’t, is not hearing loss but, rather, the appraisal of threat that the amygdala assigns to the tinnitus sensation.

In other words, it may be that the people who experience bothersome tinnitus remain on chronic alert to the sensation, while those who interpret the tinnitus sensation for what it is—a meaningless, benign body sensation—are able (automatically/ sub-consciously) to allow the sensation to drop into the recesses of awareness.

In people experiencing bothersome tinnitus, for some reason their amygdala misinterprets the sensation and convinces the mind that it is a danger (or a possible danger, needing close monitoring), when that sensation actually is just one of a million body sensations that we experience in any given moment.

So the question then becomes: How can we convince our amygdala to just “chill out” about the tinnitus and reappraise its meaning?

We know through science and experience that tinnitus—in and of itself—is not a cause for alarm and can safely be sent to the recesses. How, then, might we reassure ourselves of this and assist the amygdala in choosing the more benign response?
Brain Training

With methodologies such as those I’ve developed through MBTSR, a central goal is to help participants train the brain to convince the fast-acting and mis-appraising amygdala that keeping tinnitus in our awareness is a waste of good 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 sits just behind the forehead and conducts our executive functioning tasks, including: judgment, reasoning, emotional regulation, bringing awareness to certain things, and awareness control.

This conscious part of the brain can be enlisted to exert more control over bringing awareness to certain processes such as fear modulation and response flexibility (i.e., think before you act). The goal here is to “chill out” the amygdala, so that we can recruit and utilize a more accurate appraisal of the tinnitus sensation.

The pre-frontal cortex is slightly slower in processing than the amygdala and this, in part, explains why our brains, quickly and reactively, tend to place sounds in the “better-safe-thansorry” danger category.

We know from research into brain anatomy and physiology that, when directed, the pre-frontal cortex sends fibers to the overactive amygdala. These fibers are called down-regulating neuropeptides, or GABA, and they serve to calm down this area so that we can use reasoning to put tinnitus in the benign category, where it belongs.
Toward a Larger Pre-Frontal Cortex

Recent studies in mindfulness have focused on what happens in the meditating brain. One such study1 concentrated on the experienced vs. non-experienced meditators and found that experienced meditators have a larger pre-frontal cortex. This suggests that they were more effective in sending information to unconscious areas of the brain, which can exert more influence on ability to regulate emotional response, such as fear. This study also determined that the size of pre-frontal cortex is correlated to number of years of experience with meditating.

These discoveries support the Hebbian theory: “Neurons that fire together wire together.” When we practice thoughts and actions (i.e., regular yoga and awareness building), we can strengthen connections within the brain. And these connections have a better opportunity to inform our actions and reactions, as with how we choose to respond to incidents of tinnitus.

Such practice contributes to our creating new neural networks so that these pathways can help us correct a misappraisal of the amygdala, allowing us to keep our attention open for other, more important stimuli.

Presented through, the MBTSR program focuses on helping people uncover their own internal resources toward a reinterpretation to incidents or persistence of tinnitus. I fully believe that, with practice, most people with tinnitus are capable of More Firing, More Wiring: attaining that larger pre-frontal cortex in order to respond with a greater, more measured balance and live in healthier ways.
A Combination of Disciplines and Devices

The MBTSR course is not a replacement for any medications or devices people with tinnitus are using. Rather, the program is designed as a complement to existing therapies.

Some common questions and statements made by people with tinnitus:
  • Will my tinnitus make my hearing worse?
  • Can loud sounds and noise make my tinnitus worse?
  • If I didn’t have tinnitus, I wouldn’t have so much trouble hearing.
  • My tinnitus interferes with my ability to hear.
  • If I could fix my tinnitus, then I could hear again.

It is not uncommon for people with hearing loss and tinnitus to believe that their tinnitus is the cause of their difficulty hearing, especially when in groups or in loud settings. However, tinnitus is a symptom of hearing loss but not the cause. An undiagnosed hearing loss may be at the root of the hearing difficulty, rather than the tinnitus itself. As we know, a visit to the audiologist for an audiogram will clarify if hearing loss actually exists.

Hearing aids amplify external sound, which may result both in better hearing and the tinnitus becoming less noticeable and more manageable. The stress and fatigue that often results when a person is straining to hear may also exacerbate tinnitus annoyance. Hearing aids, therefore, can improve hearing, while reducing tinnitus bother for some people. Some of the reasons why:
  • A reduction in stress related to difficulty in hearing.
  • A lessening of demands on the parts of the brain that determine whether a sound should be paid attention to or ignored.
  • A reduction in the perception of tinnitus by amplifying sounds in a person’s surroundings.
  • “Easier” hearing helps to reduce stress and increases relaxation.

With positive metrics—both quantitative and qualitative—from participants, MBTSR approaches the challenges for those with tinnitus in a holistic manner. Combining disciplines and devices, I am extremely encouraged about making the possibility of healing a reality for those with tinnitus.
The Bridge

Like the practice of awareness building, the MBTSR is simple but not easy. As an online course, the only requirements are Internet access and the participants’ commitment to the program. (I also strongly recommend a yoga mat and a copy of Full Catastrophe Living by Jon Kabat-Zinn.)

Yes, MBTSR participants have an online discussion board in which to share their experiences, and I certainly encourage them to take their newly uncovered and strengthening inner resources out into the world.

MBTSR underscores the notion that those with tinnitus are not alone. Still, by its very nature—a virtual learning environment— the program is not readily conducive to a tangible community. And, all too often, the effects of tinnitus can include isolation and reduced sociability.

As such, I’ve proactively developed the MBTSR Education Partnership Program, in which audiologists and therapists administer group sessions for those with tinnitus who are taking or have taken the online program. These local sessions are designed to provide a “missing link” to augment and deepen the personal, online experience and help connect fellow tinnitus patients/clients in ways that the online program, by design, simply cannot.

The Education Partnership Program, then, becomes an ideal bridge for participants between any sense of isolation and the knowledge, the reinforcement, and the value to be had by sharing their experiences and perspectives with a tangible community.

Practitioners have access to an online handbook, which complements the participants’ weekly sessions. The online course itself provides the structure; practitioners engender their communities by leading and actively listening.

I believe that the tangibly interactive, confidence-building experiences the MBTSR participants find in these group sessions will become an essential component of expanding the potential of opportunity and success for those with tinnitus to live—comfortably and vibrantly—with their conditions.    

1 Lazar, S.W., et al., (2005) “Meditation Experience is Associated with Increased Cortical Thickness,” NeuroReport, 16(17): 1893-1897. http://www.
Jennifer Gans, Psy.D., is the Founder and CEO of She is a San Francisco-based clinical psychologist specializing in the psychological impact of deafness, tinnitus, and hearing on well-being. Dr. Gans is on the Board of Directors of the Tinnitus Practitioners Association (TPA), a non-profit professional organization dedicated to providing tinnitus and sound sensitivity care.