OK. Finally ...
Let me try to put it all into some sort of meaningful perspective.
The material I have discussed above is all consistent with the Neurophysiological Model of Tinnitus. The Neurophysiological Model is a theory. It is not fact written in stone. Moreover, my explanation above is not the only way to look at the model, but it makes sense to me as a physician who has a particular interested in neurophysiology (i.e., how the brain functions).
The treatment approach upon which
@emily-anne has embarked, Tinnitus Retraining Therapy (TRT), is based upon the Neurophysiological Model. There are other effective treatment approaches and various other models, but in this thread I am referring to the Neurophysiological Model and to TRT because that is the framework within which
@emily-anne has chosen to work.
TRT has two components: TRT counseling and sound therapy. TRT counseling is designed to help the tinnitus sufferer understand his or her tinnitus in terms of the Neurophysiological Model. Usuaklly there is an initial TRT counseling session and three or four follow-up sessions. The follow-up sessions, which are considered to be essential, are designed to go into further detail and to answer additional questions in terms of the Neurophysiological Model as well as address issues with the process
and with the sound therapy as they might arise. I have discussed the sound therapy component of TRT in other posts. Here is one explanation as it applies those TRT patients who have been instructed to use wearable broadband sound generators:
The philosophy behind wearing the devices is simple.
First, just as a candle looks less bright in a room with the lights on softly than it does in a room that is completely dark, so too adding in some low-level constant background sound via wearable devices can make the tinnitus seem "less bright" and consequently easier to habituate over time.
Second, there is the concept of associative conditioning. To a person with severe tinnitus, the tinnitus sound is typically unpleasant, intrusive, threatening, aggressive, and of great interest (to say the least). If TRT devices are set properly, the sound that they emit should be neutral (i.e., not unpleasant), non-intrusive, non-threatening, benign, and uninteresting. Moreover, even though the sound from the devices should approximate the tinnitus sound, it should not overpower the tinnitus. Finally, because the sound from the devices is so ... boring, if you will ... within a few minutes of wearing the devices you should be largely unaware of them. The theory is that the long-term consequences of wearing devices set in such a manner while approximating the tinnitus is that eventually the brain should begin to view the tinnitus as neutral, non-intrusive, non-threatening, benign, and boring. Which makes it easier to habituate. That's the theory, anyway.
The goal of TRT is the facilitation of habituation of tinnitus by getting to the point where the brain classifies the tinnitus signal as neutral. I have explained the importance of the brain's classifying the tinnitus signal as neutral earlier in this thread, and TRT purports to accomplish it over time through the dynamic interplay between the TRT counseling and the sound therapy.
So with that framework, I think we can now turn to
@Emily-anne's questions.
I will pick up where we left off.
How does the brain have the ability to move something from the category of extremely negative, to neutral?
Let me answer with a question:
Can you see the brain moving something from the "category of extremely negative" to "negative but less than extremely negative?" I suspect you can because it happens in real life all the time. The simplest example I can think of is an "acquired taste." Just as hearing happens in the brain and not in the ears, so too taste happens in the brain and not on the tongue. And for a taste to be "acquired" the brain has to move that particular taste away from the category of extremely negative.
One of the problems with the Neurophysiological Model, as I see it, has to do with all the boxes often used to illustrate it:
The boxes make habituation look like a rigid compartmentalized all-or-nothing phenomenon rather than a dynamic process. Sure, the arrows lend a sense of flow, but habituation is in no way an absolute! In other words your tinnitus does not have to be 100% classified as "neutral" in order for you to feel better.
Recall earlier in this thread where I wrote:
So let's start by defining habituation. Earlier I said that habituation is a "is a natural process whereby you tend to react to your tinnitus less and less over time, and whereby as a consequence you tend to be aware of your tinnitus less and less over time unless you purposely seek it," but that description really does not capture anything about the mechanisms involved. There are a few good definitions that take mechanism into account. For the purpose of responding to your particular question, I am partial to the following definition: "Habituation is the passive extinction of a conditioned response to a neutral stimulus."
The conditioned response (i.e., your reaction) in this case is "I feel bad." Why that particular response? Because if your tinnitus did not in some way or other make you feel bad, then while you would still have tinnitus, you really wouldn't have a problem. Being distracted, being upset, being worried, being anxious, being sad, etc. – all of that falls under the umbrella of feeling bad. And if you did not react to your tinnitus, then you would not feel bad. You could not feel bad. Because feeling bad is a reaction! Moreover, as a hugely important corollary, if you reacted less to your tinnitus, you would feel less bad. (We will get back to that later.)
Well, this is the later we are at long last getting back to.
For the life of me, I cannot imagine a world where this sound continues, and I simply don't react to it.
I hope that by virtue of my posts in this thread you are coming to understand that it is not necessary for you to arrive at a point where you do not react to your tinnitus at all in order for you to enjoy meaningful relief to your great satisfaction. Habituation is not an all-or-nothing proposition. It is a process. Not only that, there is an ebb and flow element to the process. Things do not proceed in a straight line. It's more like a sine wave with overall positive slope.
In addition, the notion of habituation of perception (which has many many success stories on this forum) seems absolutely unreachable to me.
The term "Habituation of Perception" (Hp) was coined by Dr. Jastreboff to fit in with his Neurophysiological Model. As any physiologist will tell you, habituation is 100% about reaction; you cannot habituate a perception. In adopting the term Hp, Jastreboff was trying to convey that the less you
tend to react to a stimulus, the lower your brain
tends to put that stimulus on its priority list as your brain
moves it towards neutral. Please note my use of the
italicized words in the previous sentence. So I think that while Hp paints a pretty picture as some sort of state, in his using the term Dr. Jastreboff has unwittingly misled many people.
But it actually gets worse. Dr. Jastreboff's colleague, Jonathan Hazell, writes on his website:
"The final stage of habituation is when the signal is no longer detected, and cortical neurones are unresponsive." The thing is, if your tinnitus cannot be detected because the associated neurons in the brain are unresponsive, that would be a cure. And whatever TRT is, it is absolutely not a cure. So while Jastreboff has unwittingly painted an unrealistic picture in his coining the term Hp, Hazell is out and out misleading in his suggestion that TRT can take you to a point where you cannot detect your tinnitus even if you try. And to my way of thinking, that is inexcusable. [If while you are doing TRT one day you realize that you cannot detect your tinnitus upon purposely listening to it, that's great. But it has nothing to do with your TRT! It can happen to anybody at any time - TRT or no TRT.]
What is it about the brain and overcoming barriers to habituation that eventually allows people to completely reframe and re-categorize the constant sound from something negative into something that isn't an issue?
I know I am repeating myself in several different ways, but I do not believe that people completely reframe and recategorize anything. I do believe that you can arrive at a place were your tinnitus is
largely not an issue in your life or where your tinnitus
for all intents and purposes is not an issue in your life - but once a person has truly suffered from severe intrusive tinnitus, no matter how far that person travels along the habituation highway, some of the effects are bound to linger. At least that is how it has been for me.
Stephen M. Nagler, M.D.
Member
