It seems to me there is quite a lot of ambiguity out there about the difference between having tinnitus and being distressed by it, even though the difference has been clear for many years now in the research carried out in terms of prevalence of tinnitus.

There is a high prevalence of tinnitus (around 1 in 10 of the population); however, 85% of those 1 in 10 habituate (get used to) and as a consequence, are not greatly distressed by having tinnitus. There are relatively simple indicators - the validated tinnitus distress questionnaires such as the Tinnitus Functional Index, the Tinnitus Handicap Inventory along with several others - that can be used to identify levels of tinnitus distress, so there are clear mechanisms to identify tinnitus distress and the lack of distress.

Taking myself as an example here, I have had tinnitus since 1993 and I most definitely include myself in the 85%. I am not distressed by it, lucky for me I never was; in my opinion, it's because I knew what it was when it began. It's true I would sooner not have it! But it is equally true that I’m not distressed by it. The key in my own case is “I knew what it was”.

"I knew what it was" - five little words with so much power, they made the difference to me between being distressed about it or not. Having “it” held no implications for me, and for that, I am eternally grateful!

What ever happens to us in life, what ever situation, what ever circumstance, has “implied meaning” to us. That implied meaning originates from what we believe we know and our understanding of it, including when that understanding is unknowingly faulty, skewed, learned from others, from what we read about or are told by others.

It’s the “implied meaning” and subsequent imaginings that cause us to react to any given circumstance.

Let's take an everyday example of what I mean by "implied meaning":

You are expecting a call from a friend to make arrangements to meet up. But she doesn't call. You wait a few days, a week, and still there is no call. What do you do? Forget about it? Highly unlikely! What might go through your mind (ruminating/implied meaning)?

There could be a thousand and one thoughts (implied meanings) to have had! One leading to another.... imaginings with meanings, most - if not all - with no truth in them. They are ruminations, imaginings, but the emotions we experience as we are having them are very real indeed. From minor upset to anger and bitterness.

Wouldn't it have been easier to have picked up the phone and just called her? Chances are, she'd answer and apologise profusely because she forgot to call!

These implied meanings come about through using COGNITIVE DISTORTIONS (distorted thinking/understanding). They ALWAYS make us feel "bad" in some way through triggering emotions that make us feel uncomfortable and unhappy.

Earlier, I explained that I am one of the 85% of people who have tinnitus. It doesn't cause me "distress", I only hear it when my attention goes to it and when I hear it, I will usually notice whether it's loud or maybe not so loud. But it has little to no meaning to me - I "know" it's there and I also "know" there's no pill that will take it away - no matter how much I may WISH there was.... although my thoughts/ruminations don't go down the route of "wishing" because I KNOW there isn't! I have been lucky enough never to have formed a HABIT of thinking negatively about tinnitus. Because I never formed the HABIT, there was no HABIT to grow in to a COMPULSION (stronger than a habit)

This is not the case for the 15% who remain non-habituated! They - for whatever reason - never did "get used to having tinnitus" or to "tinnitus being there".

Provided all pathologies have been ruled out (done through a medic - usually ENT), where tinnitus distress is present, it is ruminations (implied meanings) that are responsible for "distress" (emotional reaction). The Tinnitus Cognitions Questionnaire can help you identify some of yours, and here are just 4 of the (hundreds if not thousands) implied meanings people have that become habitual - if not compelling:

Each one of them have Cognitive Distortions behind them. For example:

"I can't get away from this awful noise"

Cognitive distortions: Magnifying the negative, Minimising the positive, Catastrophising

Rationally, it could be replaced by "I keep thinking about the noise and reacting to it - there are times, albeit only short periods, when I think about other things"

"I hate it because it's ruined my life"

Cognitive distortions: All or nothing thinking, Emotional reasoning

Rationally, it could be replaced by "I do other things - I have family/friends. Experiencing tinnitus has spoiled my enjoyment of some activities, but I do still have a life and people who are important to me"

"No one understands how bad it is"

Cognitive distortions: Jumping to conclusions, Mindreading, Labelling, Other-blaming

Rationally, it could be replaced by "No one else can hear my tinnitus so they aren't going to know what it sounds like to me. There are times when it seems worse than others"

"I will always feel like this"

Cognitive distortions: Predicting the future, Magnification of the negative, Catastrophising

Rationally, it could be replaced by "I am assuming I will always feel the same as I do at my worst and I am at my worst at the moment. I don't know how I will feel in the future because no one can predict the future - including me! Because there are times that feel worse, that is a good indicator that there MUST be times when I am not feeling as bad"

It is by identifying and then challenging the habitual ruminations (implied meanings) that enables us to change how we feel, therefore bringing about a change in how we behave - we grow better, more rational HABITS of thinking.

My work is with people struggling with tinnitus distress. More than 50% of those I work with have severe or very severe tinnitus distress, and very often anxiety and/or depression too. NONE OF THEM ONLY HAVE TINNITUS. None of them are like I was back in 1993 or since, although they do get there. They DO reach that "place" in their minds where tinnitus is there when they give their attention to it; but because they don't care about it - because they no longer live with the "implied meanings" they used to have, there is little in the way of tinnitus distress any more. Some examples are on other websites here and here, with some typical Outcomes here.

This is precisely what CBT (Cognitive Behavioural Therapy) for Tinnitus is for: To develop understanding of Implied Meaning and the Cognitive Distortion mechanism in order to achieve the breaking of old patterns of behaviour (habits) and as a result, eliminate distress.

Please note: The website www.tinnitusmanagement.com is currently being updated

There’s invariably history behind having panic attacks but, contrary to what is often assumed, it isn’t necessary to go digging up the past to find out what it was.

What counts is where you are NOW!

Watch the video to learn this easy and highly effective 2-part technique. Although it is used in the Tinnitus E-Programme, it is for everyone - with and without tinnitus!

For more help with Anxiety and Stress, have a look at the De-Program Anxiety intervention HERE

Who’s in charge of your life? What happens when you give up the pilot’s seat to another? What happens when you get wrapped up in the stuff of life, mind-wandering, worrying, ruminating, day-dreaming, imagining ... your plane is on auto-pilot.

Did you know most of us spend almost 50% of our awake time in autopilot mode? 46.9% according to an article in Psychology Today https://www.psychologytoday.com/gb/blog/your-brain-work/201011/new-study-shows-humans-are-autopilot-nearly-half-the-time

When in autopilot mode, you are not piloting your own life. Rather, you become particularly susceptible to taking on others’ views without validating for yourself whether you agree or not, whether they are in fact true or not. And who’s to say what’s true for another person is true for you, or for me?

Being in autopilot mode, we make automatic judgements. We don’t consider what we are judging, we simply react “in judgement”.

These two aspects of life are what we are doing nearly half the time we are awake!

So what about the other 50% of our waking time? Are we piloting our lives responsibly enough to be licensed? Would you set foot on a real plane if you knew for 50% of the flight, the pilot wasn’t paying attention?

Maybe you would if you were still in autopilot yourself, auto-judging that “he’s the pilot, so he must know what he’s doing”. Sadly, spending as much time as we do in an unthinking, mind-wandering state, we leave ourselves at the mercy of arbitrary decisions that have consequences for us and those close to us.

Here’s an easy test you can use to see how long you can stay out of autopilot mode.

Focus on your breath - breathe a natural breath in through your nose and out through your mouth. Not a deep breath - totally natural depth and natural rhythm. Ok, now you know what to do, set a stop watch to zero. As you begin breathing, start the stop watch.

Breathe in through the nose - cool air, breathe out through the mouth - warm air. Again, and again. Continue focusing on the cool air as you breathe it in through your nose and out through your mouth.

As soon as you notice your mind wandering, thinking about anything other than the feel of the air as you breathe in and out, stop the stop watch.

If you managed to do this for a whole minute, well done! Most people don’t even manage 20 seconds of it to start with!

In fact, this is the breathing exercise everyone I work with, whatever they come to me for, starts with. Though the reason isn’t to test their autopilot kick-in time!

*The breathing exercise done regularly (minimum 3-6 times each day) alters your neurobiology reducing arousal (stress activation) and simultaneously increases ventral vagal parasympathetic nervous system activity (calm activation/relaxation).

Try it yourself! With practice, the autopilot kick-in time extends too.

*This exercise is #Practical 1 for the Tinnitus E-Programme, De-Program Anxiety (both online interventions) and in all my 1-1 clinics.

Anxiety: Why is it that so many of us wait until symptoms are so bad before we DO something about it?

Anxiety really has become “a silent epidemic”. Up to a third of the population live with anxiety, 40% of the population with anxiety or depression (Anxiety UK)

Would it not make sense to DO something BEFORE the symptoms are so severe, you have to visit the GP and their prescription pad?

Much of my clinic time is spent helping people reduce anxiety from severe to “normal” levels of anxiety. And yes! There are “normal levels of anxiety”! It’s perfectly normal to feel a rush of inner sensations when something unexpected happens, for example. But those feelings dissipate quickly. It’s mainly adrenaline (quick release and short lasting) that floods the body causing the sensations. But within minutes, the body is back in equilibrium and we go about our daily business.

Mild, moderate and severe anxiety (beyond “normal anxiety”) is when we barely notice an adrenaline rush, because there is constant disequilibrium in the body, mainly caused by high levels of cortisol (a steroid hormone). Too much cortisol is toxic to the body, and because there are cortisol receptors throughout the body, it affects pretty much everything we do and how we feel (our mood). Cortisol is long lasting, and ends up being produced constantly by the adrenal glands situated near the kidneys. It’s often why, when we’re stressed and anxious all the time, we experience a dull ache in the back - but headaches and muscle aches are also symptoms experienced because of the far reaching effects of cortisol.

If you are noticing a constant tension in your body, butterfly sensations in the abdomen, some difficulty focusing or concentrating, the likelihood is your anxiety levels are higher than they could be.

I am looking for people with mild-moderate anxiety levels to test my DeProgram Anxiety programme as a Self-Directed intervention. So far, 95% of those offering to participate have anxiety too severe to be expected to cope without additional Therapist Support.

At some point though, all those people started with mild symptoms. This is a great opportunity to “nip anxiety in the bud” by catching it early and PREVENT anxiety from becoming worse and adding to the epidemic!

I have many really interesting cases of people coming to me for help with tinnitus, the most interesting being really quite complex where tinnitus isn’t the only problem they are trying to cope with.

One such case is a lovely chap - let’s call him “Len” for the purposes of this case.

Len was first referred to me via a solicitor. He had been getting in to a lot of trouble with the local council because of a noise “war” being waged between him and his next door neighbour, and he was being accused of breaching a second noise abatement notice. Not only was he being accused of this, but there was an impending court case (criminal court) with a real possibility of a jail sentence!

Issues around all this had been ongoing for over 8 years! Len was coming up to his 70th year, and had been put through the wringer including there having been a mistaken diagnosis of “musical hallucinations”, being coerced in to taking antipsychotic meds, and vilified in a psychiatric report because he stopped taking them (they made him feel ill) because according to the prescribing psychiatrist the meds reduced the “musical hallucinations”. He was also bullied by officers from environmental health during interviews that were conducted in a police station. Transcripts of those interviews clearly demonstrated bullying.

Arrangements were made via the solicitor for Len to be brought to my clinic for a full assessment, including an audiological assessment. Hundreds of pages of records including transcripts of interviews accompanied the referral.

My role was as Expert Witness to the Court on behalf of the defendant, ‘Len’. Prior to the pre-court hearing, I asked Len’s solicitor what were the chances of the charges being dropped to which she replied, "highly unlikely" as the council were determined to have him removed from his home. This would make Len homeless.

I was shocked. I hadn’t realised there was any way that a council responsible for homing could also render people homeless!

There was very little notice given to fit in the assessment and produce a full court report, as the solicitor had great difficulty finding anyone who could act as an Expert Witness to the Court. I completed my report and submitted it 2 days before the court hearing, one day before the pre-court hearing. The prosecution dropped the case at the pre-court hearing after reading my report, so Len was spared the court and possible jail, and no doubt hundreds if not thousands of pounds were saved in court costs.

This did not resolve the longer term situation for Len, the neighbour or the council though. Nothing practical was offered to Len (or the neighbour) to help work through these difficult issues; on the contrary, I found out through a chance meeting some months later with an audiologist who knew Len, that the whole scenario of a further noise abatement notice was imminent.

Following the prosecution dropping the case, although I had asked the solicitor to inform Len if he would like to attend my clinic for help that I would happily provide it, it turned out that Len had not been made aware of this. So, now some months later on, the audiologist passed this information on to Len, and arrangements were subsequently made for him to be brought along to the clinic again. In addition to the presenting hearing and tinnitus related issues, Len is not in the best of health and his mobility isn’t good. Public transport is not therefore possible for him, and he can walk no distance without being in pain.

Although I was offering to work pro-bono to help Len, the council refused to fund transport for him to attend and even withdrew the little support he had of a council Intervention Officer.

It was then that I sent a strongly worded letter to the council in what I suspected would be a futile attempt to have the council fund taxi transport to bring Len to appointments, the local Audiology department copied in to also receive the letter.

To my surprise, after several weeks, the council agreed!

At the time of writing this, I am part way through my work with Len. With some now 10 years of ingrained belief that his neighbour has been taunting him by playing loud music and turning the volume of her TV up to deliberately provoke him, and the belief that the council representatives have that Len is a troublemaker, is this situation resolvable?

To my mind, both Len and his neighbour have been let down by the “authorities”. The situation has been escalated to such a point that there can be no “winner”! My work with Len is ongoing, and one factor has changed just this week. That is that the council has agreed to move Len’s neighbour, although how long that might take is an unknown.

This situation is an on-going one, and Len is slowly coming around to the idea that the "music he hears from next door" - that when (during his initial assessment) I asked what EXACTLY is it that you are hearing, Len replied "it sounds like boom-boom-boom". He had (understandably in my opinion) interpreted that noise as being the base sounds of music playing.

There had been occasions - many of them over the years - when Len had become so angered by the "noise made by his neighbour" (that the neighbour denied making) that he "upped the ante" and turned his music or TV up louder and/or banged on the partitioning wall shouting at the neighbour to shut up!

Len had, in fact, made every effort to help his situation. He had used headphones for years to a) try to help block out the noise from next door and b) to listen to his own music or TV at a low volume. Again understandably from my point of view, the headphones did not block out the noise from next door! It wouldn't do so of course, if the noise was in fact being produced "internally" as tinnitus is, whatever the cause or type of tinnitus it might be.

He describes in addition to the intermittent "boom-boom-boom" noise a constant "sizzling" noise that he does - and did - accept as being "tinnitus". Unfortunately, when he was seen by psychiatry, he was labelled by them as having "musical hallucinations" - rather than tinnitus.

To further complicate the issues around this, Len has severe hyperacusis. This means that even when he does turn up his own music or TV, he can only bear the intensity for very short periods of time because of the pain it causes him. His high arousal state (when becoming angered) would enable him to cope maybe for a few minutes longer than when he was calm. However, all the years of animosity between he and the neighbour, PLUS the council's attitude toward him and their repeated threats of noise abatement notices, are not exactly condusive with feelings of calm.

There is a further 'complication' for Len, and that is he has high frequency hearing loss and (unusually and particularly so at his age) exceptionally acute hearing in the low and mid-frequencies.

To qualify what I mean more precisely by ‘non-complex tinnitus’, much of my day to day clinic work is spent working with people who have distressing but ‘non-complex’ tinnitus. Tinnitus is the sole significant presenting issue, with no “co-morbidities”. Most commonly, non-complex tinnitus is idiopathic in nature – in other words, the cause is unknown and complications in terms of pathology have been medically ruled out.

The process I use involves teaching the neurophysiology of tinnitus and methods of altering the neurobiology to begin impacting the physiological drives that perpetuate distress. In most cases, this simultaneously reduces tinnitus loudness perception.

The process continues by using specific aspects of the cognitive behavioural model to challenge the underlying meaning that the person’s experience of ‘tinnitus’ has to him/her, enabling his/her perceptions to change.

Even those whose tinnitus does not vary in loudness i.e. where loudness does not vary, for example when due to whiplash, the meaning that tinnitus used to have alters and they are able to ignore it. This process on average takes between 12-24 weeks.

I would point out that although the above is standard in my practice, access to clinicians with the skills to deliver this process is not widely available and is unlikely to be so without considerable investment in training for appropriately qualified and experienced health professionals.

NOTE: For a significant proportion of people who have distressing tinnitus, and certainly when a THI (Tinnitus Handicap Inventory) score indicates mild-moderate tinnitus distress (18-56%) I have made available the ‘core treatment’ in the form of online content plus 1-1 contact with me available online through the Tinnitus E-Programme.

Tinnitus E-Programme: www.tinnituseprogram.org

What Is Your THI Score? www.tinnituseprogram.org/what-is-your-thi-score-.html

Tinnitus E-Programme Mission Statement, Aims & Objectives are here: www.tinnituseprogram.org/mission-statement.html

For those wishing to work one to one with me either in my clinic in Clitheroe (Clitheroe Therapies Clinic) or online if you live too far away, you can use the booking form on this website: Tinnitus Assessment Booking Form

The complex tinnitus case studies in this section go beyond the ‘normal’ day to day practice described above. More details are in the website here: Non-complex and Complex Tinnitus

One of my tutors from my MSc days shared this video today - she's great at finding them! And WHAT a find this one is. Amazingly it was recorded back in 2012, but feels as fresh as though it was done today.

The video is 19:30 minutes - please do NOT let that put you off! It is SO worth the watch!

The Common Illusion of ‘Control’ Part 1                               Date: 9 July 2018

Just for interest’s sake, I’ve found a couple of NHS definitions of stress and anxiety:

“Stress is the feeling of being under too much mental or emotional pressure. Pressure turns into stress when you feel unable to cope. ... Stress causes a surge of hormones in your body. These stress hormones are released to enable you to deal with pressures or threats – the so-called "fight or flight" response.” Ref: https://www.nhsinform.scot/healthy-living/mental-wellbeing/stress/struggling-with-stress

“Anxiety is a feeling of unease, such as worry or fear, that can be mild or severe. Everyone has feelings of anxiety at some point in their life – for example, you may feel worried and anxious about sitting an exam or having a medical test or job interview.” Ref: https://www.nhs.uk/conditions/generalised-anxiety-disorder/

There are many more, even some of which directly contradict one another!

To understand stress and/or anxiety, or it's link with tinnitus, it isn’t important what word we use to describe it – anxiety or stress. Both have the physiological symptoms impact of the HPA Axis.

If you are interested in learning a little more in depth about the Neurochemistry involved in stress, there is an excerpt from The Psychotherapist’s Essential Guide to the Brain by Matthew Dahlitz (2017) available by clicking on the link here

If you have a specific question you are concerned about regarding your psychological wellbeing or tinnitus, ask your question here and I will do my best to answer!

I have been working as a therapist for over 25 years now, and even though that seems a long time - even to me - I never stop learning! Whether there is new research being published in the tinnitus or psychotherapy fields, or I come across particularly interesting pieces of work with my patients, I will be sharing some of it here.

I have always had a passion for the physiology and psychology behind how we feel, what we think and why we behave the way we do. Of late though, there is some fantastic information being researched and published from the field of neuroscience and my own interests have been jettisoned in this direction!

I can't wait to share some of it with you!

Debbie Featherstone MSc

Hearing Therapist & Psychotherapist

Specialist in Tinnitus Management

5 June 2018