Is There More to TRT?

I went to a TRT specialist who gave me the therapy. Basically what he did was explain to me how our hearing works and how the jastreboff model kind of gives you control over what you hear, through the limbic system. He gave me the 10-second exercise to do at home. But that was basically it. Now I'm supposed to return every 3 months for a follow-up session to report my progress if I make any.Every session costs about 70 euros! What is the purpose of TRT? is it a means to keep you calm by informing you? How can one say that TRT has a succes rate of 85% if people just naturally habituate with or without TRT...How can TRT make a difference?

 

I have not done TRT, but I believe the sound generators are a big part of the program to dampen the tinnitus signal. If you look at this: http://studentacademyofaudiology.com/sites/default/files/journal/JAAA_11_03_05.pdf it is a paper authored by the creator of TRT.

And scroll to page 169 it says: "Consequently, the conscious realization of the benign nature of tinnitus is not sufficient to remove these[averse] reactions, and a significant amount of time is needed for their gradual extinction."

So, there seems to be more to it than just understanding T on an academic level. I assume the noise generators are the missing piece of the puzzle.

 

And what if I can handle my T in silence? I mean I only hear it then. It bothers me but when I'm busy I don't pay much attention to it.

 

TRT is a treatment protocol devised by Dr. Pawel Jastreboff and based upon Dr. Jastreboff's Neurophysiological Model of Tinnitus, which he first described in 1990. The details of the model are not crucial to this discussion, but it is of value to understand its fundamental principle: In clinically relevant bothersome tinnitus neurological systems other than the auditory system are dominant (PJJ, 2012). The most important of these systems are the limbic system (emotion) and the autonomic nervous system ("fight-or-flight").

Where did the name "Tinnitus Retraining Therapy" come from? Consider for a moment the chair you are likely sitting in right now. You have been sitting in it for quite a while, but until I mentioned it to you, you have been unaware of the pressure of the chair against your buttocks. You might have been aware of it just as you sat down, and you are aware of it now that I am pointing it out to you, but other than that you have been unaware of it. And within a few moments I can pretty much guarantee that you will be unaware of it again – unless I draw your attention to it. One might say that the reason you are unaware of it is that you do not react to it. And the reason you do not react to it is that your brain classifies it as a neutral stimulus. The brain, even the brain at rest, is a very complex and busy organ. As such the brain must prioritize. The brain simply cannot attend to everything at once – so it places neutral stimuli way down on its priority list. What does all that have to do with tinnitus? Well, like the pressure of the chair against your buttocks, tinnitus is a stimulus. Of course, it's an internally-generated stimulus instead of an externally-generated one. And of course, there are a number of aspects of your tinnitus that make it far far different from the pressure of that chair. But in the final analysis, it is a stimulus, and if your brain can somehow be retrained to classify your tinnitus as a neutral stimulus, then you should largely cease reacting to it, and it should largely fade from your awareness unless you purposely seek it. Just like the chair. And that is where the name Tinnitus Retraining Therapy came from.

There are a number of TRT studies available for review. And even if you throw out Dr. Jastreboff's own studies on the grounds of potential bias, the others all pretty-much conclude the same thing – a success rate in the neighborhood of 85% with success defined as a significant decrease in reaction to tinnitus (Hr) and a consequent decrease in perception of tinnitus (Hp). TRT does not claim to make tinnitus less loud. It does, however, make it less bothersome regardless of how loud it might be (i.e., you react to it less.) The implication cannot be overstated, because – due to prioritization within the brain – a decrease in awareness is an inescapable consequence of a decrease in reaction. And if you are not aware of your tinnitus (see the chair example in the above paragraph), then what does it matter how loud it is?

TRT is a very specific protocol. It starts with an evaluation during which a person's "TRT category" is identified by his or her TRT clinician. There are five distinct TRT categories, which are inconveniently numbered 0 through 4. The numbering does not reflect severity; rather it is based on the presence or absence of hyperacusis, hearing loss, and a variety of other auditory factors. Sound therapy and TRT counseling (which used to be called "directive counseling") are the two essential elements in TRT. The particular form of sound therapy as well as the specific TRT counseling strategies are dictated by the TRT category. Thus, for instance, a Category 2 patient would receive completely different sound therapy and counseling recommendations from a Category 3 patient. Regardless of TRT category, the counseling is consistent with the Neurophysiological Model of Tinnitus and involves an in-depth description of the rationale behind habituation as well as how and why the brain classifies stimuli. The counseling involves an initial session and two to four "follow-up" sessions throughout the course of treatment – generally six to twelve months. The sound therapy might involve environmental sound, hearing aids, wearable broadband sound generators, or some combination thereof as determined by the patient's TRT category. The sound generators emit a soft "shhhhh" sound, the volume of which can be adjusted by the wearer, who is carefully instructed in how to set them each morning. The end result of the instructions is that (1) the sound does not suppress the tinnitus in any way, (2) the sound is not annoying, (3) the sound does not interfere with communication, (4) the sound does not elicit the stochastic resonance phenomenon (which can actually aggravate tinnitus), and (5) within the aforementioned constraints the sound maximally facilitates habituation. The specific details of how sound therapy is employed in each TRT category and how devices are set (for the categories requiring devices) for each is well-described in a number of publications and is beyond the scope of this review. Suffice it to say that when wearable devices are used in TRT (a) they are inconspicuous, (b) they are comfortable, (c) the sound they emit is not annoying, (d) the sound they emit does not interfere with communication, and (e) within a few minutes the wearer becomes oblivious to them. The devices are worn as much as possible but for at least eight hours a day – but since the wearer quickly becomes oblivious to the devices and to the sound they emit, that is largely irrelevant. Importantly, at the conclusion of TRT the devices are no longer needed.

Excellent question. The answer lies in the fact that the 85% figure pretty-much holds regardless of when you start TRT - twenty days after the onset of tinnitus, twenty weeks after, twenty months after, or twenty years after. The success rate does tail off just a bit the longer you wait - but if you've been miserable for twenty years .... and then a year later after starting TRT, you're doing great ... then it's reasonable to assume that more than just tincture of time has been at work over that last year.

Most ethical clinicians would have given you some coping skills and strategies, but I should hope they would not have suggested TRT. Why use a sledge hammer to shoo a fly away??!!

Dr. Stephen Nagler

 

Thank you very much for your clear explanation Dr. Nagler!

about the fact that they suggested TRT is because I'm a very perfectionist kind of person, and a couple of months back I couldn't cope with the T in silence (sleep, study, etc). This has changed for me over the months. I am still bothered by the T when I'm trying to study in my room, but I'm not panicking anymore as I did before. So you could say my reaction has changed from panic to frustration and may oneday be neutral.

What if I could sit in a silent room and force myself to be neutral about T, would this speed up the habituation process? Or would you recommend still having some noise in the background. It's just that I don't want to feel dependent of noise.

 

My ENT really didn't give me much to go on. He was convinced my T was acute and would resolve itself in the following 2 months. It did get a bit better (the sound got softer) but it didn't go away completely. He then told me if I still suffered I should seek out a TRT specialist. Which I did.

 

You are welcome.

I do not know how one can "force" oneself to be neutral about tinnitus.

I did recently present a rather detailed roadmap for facilitating habituation, and I think I'll just stick with that ...

https://www.tinnitustalk.com/threads/overcoming-obstacles-to-habituation.6886/

Hope this helps.

Dr. Stephen Nagler

 

Okay I'll read your roadmap, let's hope this works.

 

Since there is no certification in TRT, and moreover since the term TRT is not trademarked, I'd be interested in how you determined that the TRT "specialist" you saw knew what he or she was talking about. For instance, I think I know a fair bit about TRT, and I've certainly never heard of the "10-second exercise" you wrote about in an earlier post.

Time for me to back off here. All the best with it.

Dr. Stephen Nagler

 

My ENT directed me to this website http://insentis.be/
It's a Belgian website so everything is in dutch. And the 10-second exercise can be found on this website at the bottom
http://www.tinnitus.org/exercises.html

 

I am not familiar with the insentis.be site and have no opinion on that matter.

As far as the old tinnitus.org site where you found the exercise, there are a number of glaring errors there. I'll leave it at that.

Again, all the best. TRT or no TRT, it sounds to me like you are doing just fine!

Dr. Stephen Nagler

 

Here's a good link explaining how the brain filters out tinnitus after habituation has occurred.

http://www.cell.com/action/showImagesData?pii=S0896-6273(10)00325-9

Notice the sentence:

"The same signal is directed in parallel via the amygdala to the subcallosal area (which includes the NAc region of the ventral, “limbic” striatum and the vmPFC) for evaluation of the sound's emotional content."

The amygdala is the part of the brain which attaches emotional salience to signals from your five senses and fast tracks them to your consciousness. It has a 300ms headstart on your conscious minds perception of the same sensory information. It's so you can act quickly in an emergency without you having to think about it.

Your stoneage ancestors who encountered danger (a lion) and ran, tended to pass more genes on to the next generation than those who stopped to think about it.

The methodology is well understood and used quite often in the advertising and persuasion industries. Here's an academic overview

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784103/

And here's a practical application you can use with a bit of training of the same concept.

http://en.wikipedia.org/wiki/Microexpression

The gestures are triggered by your physiology reacting to the emotional information hitting your conscious mind before your conscious can mask your reaction. It's also very handy to know for chatting up girls so you know how your doing from the outset....

To speed up the habituation of tinnitus what you're doing is teaching your amygdala that tinnitus isn't a threat so can it please stop sending all this emotional colouring to your conscious mind and making you care about your tinnitus. Once the amygdala realises that T is of no concern to you it sends the signal back to your Thalamic Reticular Nucleous for cancellation. Think of noise cancelling headphones.

So in effect you don't hear your tinnitus unless you want to. It's hard to explain, but adjust your perception to the feel of your clothes on your body now. Feel them? Yes. Well that feeling was always there but there was no relevence to them so your brain filtered it out. You've forgotten them already haven't you....

So in a nut shell: Stop caring about your T and it won't bother you. If you're really relaxed or happy then have a listen to your T. It links pleasant things to the noise. Your amygdala starts thinking "definitely nothing distressing here, find something else to worry about"

I love this clip

The Trick Is ...

 

Wow that was very informative and gives me a sense of control. I like it when theories are thoroughly explained thank you

 

You're welcome. When I first had tinnitus it drove me round the bend but the turn in the road happened when I realised why it bothered me. It's like a weight off the shoulders. Sort of like having an annoying squeak in your car then all of a sudden discovering what caused it. Even if you just leave it, it doesn't bother you as much.

One thing the amygdala doesn't like is change. To your stoneage ancestors, change was usually something dangerous. Tinnitus is a change in your sensory inputs. Luckily the mind realises that change could mean opportunity and your prefrontal cortex (the thinking you) analyses the change from every angle to see if it can be utilised to your benefit.

That's why fears can be overcome through training. The PFC has an executive overide on the emotional system if the fear is a repetitive one. A new fear will always generate an override of the PFC because it could be a clear and present immediate danger; it's a heuristic which evolved millions of years ago in many animals.

Jim Jones manipulated the minds of 800 of his followers to drink cyanide and kill themselves and override the most powerful and deepest amygdalan fear of all, and that's death. Same with suicide bombers. If the mind can overcome fears like that, then tinnitus isn't even in the same ball park.

It's only an invitation to feel distressed, you don't have to accept it. You have as much control as you want to have.

 

I read somewhere in your brain filter article that it's because the filters aren't working properly anymore that we experience tinnitus. They aren't working properly anymore because we perceive tinnitus as something negative, something dangerous, something that shouldn't be filtered. Now could it be possible for someone to already have tinnitus (that gradually grew over the years, not something you'd notice immediately) without even being aware of it because of the filters working properly. And when suddenly being introduced to an acoustic trauma in which the tinnitus spikes but only temporary, say for about 2 months, to lower back again to it's normal level. But because of the spike the person is now aware of its lower tinnitus even though she could perfectly live without perceiving it before.

Because I believe this is what happened to me. I started obsessing because of the spike. Now it's not as loud anymore but there is still some noise I find annoying. And I remember waking up (before the acoustic trauma) to a loud noise every morning, but this would only last for a brief moment until I got out of bed. I never put much thought into it.

 

You're exactly right. Although the model shown simplifies the concept a fair bit [ The Auditory Cortex also has a feedback loop to the MGN, otherwise asynchronous neurons firing in the auditory cortex area and creating the phantom T sound, would never reach the amygdala] it posits the conjecture that the brain will filter out repetitive non harmful stimuli after a while.

Think of it like auditory signals being like marbles rolling down a channel. Normally the cochlea creates the marble and it rolls into MGN. [ In the case of a T the signal marbles are being fed back to the MGN]

The MGN copies the marble and sends one to the auditory cortex and one through the amygdala. As it passes through the amygdala it's evaluated for emotional content and if it's deemed to have some, it has a little "attachment" added which says : fast track to PFC for heuristic processing! [basically being made to use an evolutionary hardwired fast response track operating on autopilot] it hit's the PFC 300ms seconds before the other marble arrives and shout's "incoming, watch out!" and the first marble when it arrives receives full awareness (you're aware of the sound of the T)

The reason for this is that your ancestors emotional programmings were a quick and easy way to protect your genes from harm or promote your survival.

Unfortunately when an "emotional attachment" is fixed onto your little marble as it passes through the amygdala its "too big" to fit through the little hole letting it back in your MGN for signal cancellation.

Habituation is the removal of the attachment over time. If the stimulus is harmless and nothing of any note happens to you then this is a smooth process. Your mind is filled with repetitive stimulus from all your senses every day but it's just filtered out (like the feeling in your big toe as you read this....)

If the stimulus is harmful then the filtering is a long hard process for obvious reasons, your ancestors who found it easy to ignore usually got killed for not dealing with the danger and their genes were weeded out of existence.

Doubly unfortunate is the fact that your conscious mind (PFC) also has feedback to your amygdala and constantly reminds it to be bothered by your T and it's a vicious circle.

To speed up habituation you literally have to "fake it till you make it" with the "it" being not caring about tinnitus, you're sending PFC assurances to the amygdala that all is well and to stop sticking emotional content onto the sound, eventually it does just that; attachments aren't affixed and the signal fits through the little hole back into the MGN for noise cancellation .

Lots of people who are hard of hearing have no tinnitus and it's because it's so gradual that it gets through the amygdala undercover. Whereas a sudden loss like acoustic trauma is too big to ignore.

In your case the acoustic trauma got the amygdala out of bed and it started sticking attachments onto all the sound of your T and once the spike had subsided it's still there doing it to your original T. Stop worrying about it and it will only be there when you listen for it.

When you go to bed tonight remind your amygdala that LLLT and Autofoni are on there way so it can relax even more

Hope that makes sense. Regards Silvine

 

Haha. I'll remind my amygdala.

 

Again thank you for explaining all this Silvine!
What you are telling really makes sense en gives us some sort of power back.
Too bad they didn't tell me this back at my TRT-session

 

Is faking enough?
If somebody keeps saying that T is not harmful and everything going to be ok, but at the same time one thinks about it negatively, would this still work? Does the feeling had to be real?

 

Yes faking is enough because eventually you're not faking: It's true. Your unconscious mind is like a horse that you (your conscious mind) rides to get wherever it's going. Sometimes the horse (unconscious) and you (conscious) disagree on where you are going and in that case the horse wins as it's the more powerful of the two.

[If you've ever ridden a horse it's not like riding a bike; on a bike if you swerve into a wall then you get hurt, try it with a horse and the horse has other ideas]

You're unconscious mind has the cognitive capacity of a 4 year old child and it has four remits hardwired into it.

Food, Fleeing, Fighting and Fornication. The "four F's"

http://en.wikipedia.org/wiki/Four_Fs_(evolution)

What accelerated habituation is, is your conscious mind putting constant mild pressure to get your horse to where you want it: Habituation. By "faking" your belief that T is not harmful (which is actually true) then you use a concept called "embodied cognition".....

http://en.wikipedia.org/wiki/Embodied_cognition#Self-Regulation "
#Evolutionary View of Embodied Cognition

....to rewire your brain using a concept called "neuroplasticity" as language itself is a form of embodied cognition and if you repeat something enough times then the unconscious starts to believe it, and if you act congruently with what you're saying to yourself [T is harmless] then your whole body and brain become congruent with that belief.

http://en.wikipedia.org/wiki/Illusory_truth_effect

Thus the amygdala is receiving information in feedback loops from numerous sections of the brain that everything is ok. Eventually you gain what's called "processing fluency"...

http://en.wikipedia.org/wiki/Processing_fluency

...as the requisite neurons responsible for forwarding the attenuation signal to the amygdala become more myelinated....

http://en.wikipedia.org/wiki/Myelinogenesis

The best time to "fake it" is when you're experiencing a positive emotion, as emotion has direct access to the amygdala and has more bandwidth to it than the PFC connection.

This is exactly how hypnosis works. First you overload or put the PFC to sleep using either surprise/confusion or repetition (jerking your arm or getting you to relax and watch a swinging watch) then the unconscious mind is face to face with the real world during a process called a "transderivational search. It's very suggestible without the PFC sticking it's oar in like a doorman at a nightclub checking everything is fine with what's coming in.

If people can have dental surgery with hypnosis then that's a lot of power you have, that you didn't even know you had.

Regards Silvine

 

Awesome explanation!!!