Dr. Jastreboff and Loudness ...

Hi All -

The following statement appeared on the board in another thread:

"Still, most people with tinnitus habituate it, no matter how loud it is and no matter the number of sounds."

My initial inclination was to agree with the statement, but since that time I have given it considerable thought. For sure, most people habituate their tinnitus. But the question is whether folks who perceive VERY LOUD tinnitus are less successful in that regard.

My experience from the period between 1997 and 2002 when I ran a tinnitus center was that loudness was irrelevant - but in my clinic we used TRT in treating almost all of our patients with VERY LOUD tinnitus. Moreover, in talking to other TRT clinicians over the years, their experience in their clinics was the same as mine - loudness (even MEGA loudness, to use a phrase that has shown up here in TT) is irrelevant to habituation. Folks with VERY LOUD tinnitus have the same ~85% success rate doing TRT as folks with tinnitus that isn't so loud.

Well, today at lunchtime I met with Dr. Pawel Jastreboff, who conceived of the Neurophysiological Model of Tinnitus and invented TRT, in a local tavern here in Atlanta for burgers and beer. We are old friends and talked about a wide range of subjects, among which whether tinnitus sufferers with VERY LOUD tinnitus habituated with the same success rates as others. He said that absolutely they did. I then asked him if he was talking about every tinnitus sufferer with VERY LOUD tinnitus or only the ones who did TRT. He said that the only ones he could talk about from his own (huge) clinical experience were the ones who had done TRT. So I next asked him what he thought the impact of loudness would be on those tinnitus sufferers who tried to "go it alone" (i.e., without TRT). And he said that he imagined they would have a much tougher time habituating than those folks with tinnitus that was not as loud. I think that's the case as well.

Now clearly both Dr. Jastreboff and I are biased regarding TRT. I readily admit it. I was a TRT patient. I was a TRT clinician for several years. I have taught TRT to many other clinicians over the years. And Dr. Jastreboff for all intents and purposes IS TRT. So my post above is biased. But I offer it as food for thought nonetheless.

When folks on various boards who are trying to "go it alone" state that they would have an easier time of it if the did not have VERY LOUD tinnitus, upon careful reflection I would have to say that they are likely right in that regard. And I owe an apology to those with VERY LOUD tinnitus who might have taken offense at my earlier position to the contrary.

Stephen Nagler

 

Thanks, Dr. Nagler. That is very interesting. Thanks for sharing that with us all.
I wonder if tinnitus that keeps changing in frequency and volume and/or reactive tinnitus has the same success rate of habituation with counseling/TRT. Seems it would be much more difficult for the brain to get used to.

 

You are welcome.

In TRT none of that stuff matters. Not loudness, not pitch, not fluctuation, not reactivity. Ask any knowledgeable and experienced TRT clinician - and he or she will tell you the same thing. The success rates are the same. (The only exception is those individuals whose tinnitus gets markedly louder after noise exposure and does not begin to settle back down within 24 hours. Their success rates with TRT tend to be lower.)

On the other hand, if you try to "go it alone," I suspect it all makes a difference to some extent or other - loudness, pitch, fluctuation, etc.

Again, what I am telling you is the best information I can offer, given that it is coming from a biased keyboard. And I am certainly not promoting TRT for everybody who has tinnitus. Most folks with tinnitus habituate just fine on their own. I am telling you what Dr. Jastreboff and I discussed at lunch. And I am apologizing to any who might have taken offense at my earlier position.

Stephen Nagler

 

I'm confused. You say that: "The only exception is those individuals whose tinnitus gets markedly louder after noise exposure and does not begin to settle back down within 24 hours. Their success rates with TRT tend to be lower."
Are you saying that most people's tinnitus from noise exposure have an a set loudness level and then settles back down within 24 hours to another set level? The reason I say that is because that seems not the norm that I am finding on this board and others. From what I have seen, and including myself, most seem to start off and get worse for a period of time.

 

@beemovie, I'm saying that specifically for those people doing TRT if they are exposed to noise and as a result however loud their tinnitus was at the time of exposure it gets significantly louder and moreover does not return to where it was prior to the noise exposure within 24 hours, their success rate in TRT is lower than the expected 85% or so of others who do TRT. The term for this phenomenon is "kindling."

Stephen Nagler

 

i'm glad to hear about your change of mind regarding that issue

 

@Dr. Nagler

First and foremost I want to thank you for your participation in such an important field. I do have an inquiry though.


I would like to understand the deeper meaning, which perhaps is a semantic one, of the word “habituation”. As I understand it, the word means to decrease or cease to respond to stimulus(that of Tinnitus). Does this man that the awareness of the loudness of Tinnitus is decreased or is the emotional response muffled, perhaps both? How can you tell the difference is my essential question.


In the case of the VERY LOUD tinnitus, your objective is to habituate it into a lower stage of intrusiveness. Now what irks me is the question, what is the basis for this “evaluation of intrusiveness”, and is this evaluation independent of the state of mind the patient decides to be in? Cause if you demand from the patient to all out concentrate on the tinnitus and evaluate how it has decreased, can he/she really be surprised to sense it not having decreased at all? Or is TRT simply a way of making the mind not perceive the tinnitus, when and only when the patient is not focusing on it?


I can for instance habituate to the screaming of my infant boy, however, the intrinsic loudness of his cry for help do not decrease if I solely decide to focus on it. Could you in the very same way you habituate tinnitus also habituate my response to a screaming infant. How could you though? That would mean my hearing is being muffled, not in any sense “habituated”. Habituation would only be really existent if my state of mind is not concentrated.

 

@AliHT, what you ask is a very complex question. I will try to offer a very simple answer for starters, and we'll go from there.

The simplest way to look at habituation is "I do not care." If you don't care about your tinnitus, then however loud it might be, however pitchy it might be, whether or not it fluctuates, whether you have one tone or multiple tones, etc. is completely irrelevant. More than that, since your brain prioritizes, it can only attend to so many things at once. Even in the resting state, your brain is very busy. And if you don't care about your tinnitus (i.e., if your brain classifies it as a neutral stimulus), then regardless of its loudness, etc, you will be unaware of it (just like right now you are unaware of the pressure the chair in which you are sitting exerts against your buttocks) unless you purposely check.

In practical terms, since habituation is a process rather than a state, the best a person with intrusive tinnitus can do is largely habituate it, which means that you might for whatever reason become aware of it every once in a while when you are not purposely listening for it, but even then while it might briefly distract you, it causes you no distress.

Let me add one final note. Let's say being largely habituated is your goal. Like you live in New York and your goal is to drive to Florida. You can do it in a Ford. You can do it in a Chevy. You can do it in a Toyota. You can do it in any number of brands of cars. TRT is a brand of car. It is but one of many ways to get there.

Hope this helps rather than confuses.

Stephen Nagler

 

Dr. Nagler, in your message to beemovie, I assume you are talking about those with reactive tinnitus. I understand reactive tinnitus to spike to certain sounds, and stay that way for 24 hours or more. I have t that competes with environmental noises at the similar frequency to my t (reacts to it), but when I break from the environment, the t immediately goes back to baseline. Hopefully TRT may work for someone like me? I also have multi tones. Thanks, Dr. Nagler.

 

Lisa, as I see it "reactive tinnitus" is an incredibly ambiguous term. I myself never use the term. Why? Because most everybody's tinnitus reacts to something! Mine gets markedly louder after I eat Thai food. It also gets louder when I am fatigued or stressed. So I have reactive tinnitus - it doesn't react to noise, but it reacts to other things.

You asked about TRT. And in TRT the only thing that matters is whether or not your tinnitus gets markedly louder upon exposure to noise and stays that way for more than 24 hours after cessation of that noise. Yours does not fit that criteria - so you're fine in that regard in terms of TRT. As far as tinnitus loudness, pitch, timbre, single tone, multiple tone, fluctuation, etc. go ... in TRT none of that stuff affects success rates.

Stephen Nagler

 

that is exactly what happens to me: Dhyan Cassie also call it "kindling". I have to be so so careful with any kind of loud noise. Just a brief loud noise exposure such as Harley Davidson goes by, or truck backfire, or dental crown work: my tinnitus goes very very loud and stays that way for weeks or months. My dental crown work was 6 months ago, and I still have not recovered. that must explain why I am having so much trouble getting better: I listen to quiet music 24/7 to try to habituate, as well as Restful Rain constantly playing quietly. I am starting to have to use more and more meds to get to sleep, and i am definitely in trouble.

 

@object16, have you considered CBT or MBSR?

Also, @object16, I'm going to be the guest speaker on April 26 at Dhyan's self-help group meeting in Ewing. See you there?

Stephen Nagler

 

Thanks so much, Dr. Nagler. That is the most helpful comment I have had to date about all this. Onward and upward through TRT I go Thank you.

 

What does matter in TRT - a lot - is the knowledge and experience of your TRT clinician. So you'll want to do your due diligence there, especially since there is no formal credentialing or standardization in TRT. I like Paula Schwartz in Minneapolis, Gail Brenner in Philadelphia, and Jacqui Sheldrake in the UK very much in that regard.

Stephen Nagler

 

you are so lucky to have lunch with such a famous doctor,congratulations!

 

Dr. Nagler- I thought almost every ones tinnitus gets louder for days if they are exposed to very loud noise ..eg . Movies , concert etc. isn't that so ?
I have noise induced Tinnitus ,and it got very loud for 3-4 months after I went to one concert and second time it got louder after I went for a v loud movie .
Are you saying tRt might not be that effective for me ?

My t also goes up when I am v tired and don't get enought sleep .

 

Stephen Nagler

I really appreciate your post (very informative and helpful indeed) and I also like the link to Dr. Jastreboff's T-Model (or model T ).

My T hit me like a freight train 1 year ago (very loud, sounded like a dental tool in the center of my head -- I was quickly turning into the crazy man hollowing at the moon); at the time I knew nothing about anything regarding T (total ignorance). I happened upon Nebraska Hearing Instruments and was fitted with AudiBel A2 hearing aids with white noise generators (they were a God send). Currently, my T is way down in volume and pitch and I believe I have habituated (I can't even bring myself to react to it anymore and it is no longer annoying). My audiologist (Ed Granger) is a very unique/exceptional individual that basically 'held my hand' and got me through (we met weekly). I recall accepting my situation, taking 'baby steps' to get my life back (all the while, Ed was encouraging me, keeping me on track). The white noise generators played no small part in all of this (they are integrated with my hearing aids and are programmable to mask my T -- although my T at the beginning was so loud nothing could mask it 100%).

But none of that process was really codified (in any form); it just happened. So, did I unwittingly follow the TRT paradigms? Sorry if that is a dumb question; it's just my history with T and I'm curious.

Again, thanx for being a part of this site (you're a big help, a real blessing)

Mark

 

Hey, I'm a famous stringplayer. So maybe we're both lucky?

We've been friends for more than a decade now. Call it bad judgement on his part!

Stephen Nagler

 

For most folks exposed to noise it settles back down by the following morning. Maybe it's a question of how loud is loud? Sure, if you get exposed to a very loud noise for an extended period of time, the exacerbation might last more than a day. But that's not what I'm talking about.

I'm saying if you are considering TRT you should be evaluated by an experienced and knowledgeable TRT clinician and make a decision based upon that evaluation and not upon what you read on a message board - even if it was written by me! And by the way, that goes for any treatment protocol - not just TRT.

Irrelevant in terms of TRT.

Best regards -

Stephen Nagler

 

I personally would not attribute your improvement it to TRT. But who cares? You feel better. In the final analysis that's the only thing that matters, right?

Glad to be of help. Seems like a very nice board with some very nice folks!

Stephen Nagler

 

@Dr. Nagler - hope you don't mind me asking a quick question here in regards to TRT (feel free to inbox me if you would prefer ...) but in your experience, how long should someone try to "go it alone" before trying TRT? And does leaving it to try to habituated by yourself and failing make TRT harder?

 

Sometimes we can tune out external noises but the sounds in our head are foremost making the tune out nearly impossible. Also, the pitch is overbearing. Some sounds you can walk away from, not the ones in your head.
I like your baby example.

 

The answer is the same for TRT as for any other legitimate habituation-based protocol. Habituation is a naturally-occurring process. Habituation-based protocols can facilitate that process (i.e., jump-start it or accelerate it) - but there is no voodoo or magic to any of them. How long a tinnitus sufferer should "go it alone" before beginning a habituation-based protocol is a highly personal and individualized decision based upon the degree to which that individual is suffering and the speed with which that individual's habituation is (or is not) progressing on its own without the facilitation that these protocols can provide.

Specifically with respect to TRT, I personally know of three individuals who suffered for more than twenty years prior to starting TRT that was ultimately successful within 12-18 months. So I would say that waiting does not make it particularly harder. Having a closed mind makes it harder, but not waiting.

As I see it anyway.

Stephen Nagler

 

Hi Dr. Nagler. Really interesting Reading!! Thank you very much for this.

Do you know where I can find (if any) TRT clinics in my area? I live in Sweden (malmö), but I'm originally Danish and work in Copenhagen on daily basis.

Kenneth

 

Mine does respond to sounds, But it is more of a high shrill attachment to the sound that fades a way a second later What makes it stay longer is if I move around. Anything that will bounce my head at all is the worse. Even walking. Forget about trying to run. And if I even move quickly up and down on my tippy toes, the faster I move the louder it gets. Going up or down stairs will do it to. If I try and jump up an down quicker and quicker, it will get so loud it starts to sound like my head is going to explode. When all this happens I can move the sound from one ear to the other by tilting either ear up in the air. What ever ear is higher the sound moves to that ear.

 

Hi Kenneth -

If I were a tinnitus sufferer working in Copenhagen, my first thought probably wouldn't be TRT, but rather I'd seriously consider seeing Anne-Mette Mohr. Anne-Mette Mohr is a psychologist who has done a lot of work in what she calls "Patient-Centered Tinnitus Therapy." I personally hold her in very high regard. "Patient-Centered Tinnitus Therapy" is not TRT and has nothing to do with TRT, but if I were in Copenhagen, Anne-Mette is the person I would see.

If you are bent on TRT and only TRT, then I would contact Jacqui Sheldrake in the UK and see if she would be willing to do your follow-up TRT counseling long distance (via phone, Skype, etc.) after an initial in-person evaluation and instrument fitting in London. If she were willing to do so, then I'd make the trip to London to see Jacqui for that initial visit, and I'd do the rest with her long-distance.

Hope this helps.

Stephen Nagler

 

Dr. Nagler, do you recommend any TRT specialists in the San Francisco Bay Area? Cheers.

 

Also can you recommend any TRT specialist for me in Wyoming please.

 

Lisa, I only recommend clinicians I personally know and for whom I can vouch unconditionally. The person I really like in the Bay Area is Malvina Levy. Malvina is not a fan of TRT at all, but she would absolutely be my first choice nonetheless. Recall that in Post #8 I was writing about various brands of cars that can get you to your destination. Malvina doesn't do TRT, but she will get you to your destination safely and with compassion. And in the end it's the getting there that counts, yes?

Stephen Nagler

 

Wyoming? I would contact Paula Schwartz in Minneapolis. Yes, it's quite a distance for you. But after an initial one-day visit for evaluation, instrument fitting, and TRT counseling, Paula can arrange to do all the follow-up long distance by phone or Skype.

Stephen Nagler