Mindfulness Post CBT?

Hello, Dr. Hubbard: Thank you for being part of Tinnitus Talk. Your professional expertise is very valuable and we appreciate you taking your time to help those here.

I have been wanting to ask this question of my audiologist and thought I also might ask you:

I developed extreme anxiety and rolling panic attacks a few weeks after my tinnitus onset in May 2013. I had no prior anxiety history, although had been going through three stressful years due to continued layoffs at work. I started cognitive behavioral therapy in late July 2013 to deal with the anxiety. My therapist did not have a specialty in tinnitus but was very experienced in CBT, plus was someone I had worked with before. The therapy helped me tremendously. In late April of this year, my therapist said she felt I was doing so well that I no longer needed to see her, except if necessary.

I indeed have greatly improved, although I still feel like I have not quite reached habituation. I also am in the Neuromonics program. I do have anxiety flutters from time to time, although my CBT skills usually allows me to calm them without medication. I am able to work, have a normal life, basically do everything I did pre-tinnitus.

My question: I remain interested in Mindfulness, I guess mainly because of all the attention it is getting. But at this point, would it really enhance my habituation? Would it be important to work with someone who had expertise with tinnitus patients? These professionals are few and far between, and I tend not to be very adept at online learning.

Thanks

 

Dear LadyDi

Thank you for providing me the opportunity to respond to this important question about CBT. First of all, congratulations to you and to your CBT therapist on your success to date. Anxiety and panic are common responses to tinnitus onset, and not easy to deal with, especially on top of tinnitus! That churning mix of painful, unwanted sound, sensation, rumination, emotion create a perfect storm—a synergy of hurt—that makes everything worse. Coming through that storm is your first success in living with and accepting tinnitus.

Thank your brain, for it errs on the side of keeping you safe. And it has come to associate tinnitus with danger. When you are distressed by tinnitus, your brain is sounding the alarm – fear, anxiety, panic. These emotional states tend to arise close to tinnitus onset, when it seems impossible to even imagine yourself living with and accepting tinnitus. This is followed by a period of more subdued, prolonged hypervigilance, a state of anxious attention to the sounds and sensations of tinnitus that can be associated with anxiety, rumination, avoidance and depression.

Adjustment to tinnitus occurs at many levels of the brain. How we consciously think and act can comprise a frightened, resistant response to tinnitus, which blocks adjustment and habituation, or a soft, accepting response which promotes recovery, making it easier to redirect our attention to resuming, engaging the important work of our lives. Beneath this conscious response is the unconscious, hard wired, reflexive level of brain wherehabituationoccurs. This is the part of the brain that stubbornly holds onto fear, believing that it is keeping you safe!

Habituation is a gradual process of teaching this stubborn part of the brain that tinnitus is in fact not dangerous, just meaningless background noise. Because your brain errs on the side of caution, of keeping you safe, it may take one, two, or even more years to fully habituate. As long your brain continues to believe that tinnitus is important, is a threat that must be consciously monitored, then it cannot habituate. CBT for tinnitus is a process of identifying and removing "roadblocks" to habituation by providing your brain with opportunities to learn at both conscious and unconscious levels. The goal of CBT for tinnitus is to teach your brain that tinnitus is not dangerous, so it will stop sounding the alarm! So, if you haven't habituated, your brain is still on its learning curve – learning that tinnitus, while unfortunate and unwanted, is in fact not dangerous, and can be accepted and ignored.

The first step is education, learning the facts about chronic tinnitus, that it is not dangerous, not a harbinger of hearing loss, and disability, that the vast majority of people who have tinnitus come to ignore it, and resume their lives as usual.

And YES! Mindfulness can help! A recent CBT study compared six weeks of tinnitus education plus progressive muscle relaxation (PMR) to six weeks of tinnitus education plus Mindfulness-Based Cognitive Therapy (MBCT). PMR trains the person to release muscular tension in response to tinnitus and to apply this through the day. MBCT, modeled after Jon Kabat-Zinn's Mindfulness-Based Stress Reduction (MBSR), uses emotion awareness, acceptance and mindfulness to attain a softer, more accepting relationship with their experience of tinnitus. Both approaches are intended to ease hypervigilance, the brains major roadblock to habituation. PMR focuses on muscle relaxation to engage the body's relaxation response. MBCT focuses on acceptance and mindfulness, which may be considered a deeper level of release. Results showed that the education + relaxation group made initial gains, but lost them over time. The MBCT group made the same initial gains, and not only held their gains but continued to improve!

Mindfulness is not for everyone. It requires willingness to experience life fully, even the unwanted parts, like tinnitus. But if you can dedicate yourself to daily practice, at least ten minutes of formal mindfulness and noticing opportunities to respond mindfully over the course of day, it's very likely that within a few weeks you will begin to notice tinnitus fading further into the background. Even when it doesn’t fade from awareness, when your brain notices your tinnitus, it is with a softer emotional tone. The sounds and sensations, your unwanted emotional response – frightened thoughts, feelings, urges to run—that made up the synergy of hurt, are softer, and draw less of your precious, personal energy. This makes it easier to turn back toward the important, valued activities of your life.

Acceptance is tricky. It's one thing to accept something intellectually, logically understanding that it cannot be changed and controlled. All the evidence may support that conclusion. It's yet another, far more trying and noble process to accept unwanted challenges in your heart-of-hearts. You can think of mindfulness as this deeper level of experiential acceptance – a willingness to take on the full catastrophe that is tinnitus. When you let go of your fighting, bracing, avoiding in this way, you find the serenity to live fully even with tinnitus.

Unfortunately, there are very few cognitive behavior therapists who specialize in treating people with tinnitus (a problem I am working to correct), and even fewer who are qualified to offer Mindfulness Based Cognitive Therapy for tinnitus. Your best bet then is to find an MBSR course (Mindfulness-Based Stress Reduction). You can do an internet search by entering “MBSR” and your city/town, etc. The course will not be directed toward tinnitus, but will address similar unwanted, challenging life circumstances for which you can substitute “tinnitus.”

Again, LadyDi, thank you for providing me the opportunity to address this important area of tinnitus recovery!

Sincerely,

Dr Hubbard