Ellen Meny was a 21-year-old college student, back in her apartment and removing her earbuds after a run, when the rushing sound began. She had experienced similar occurrences before—unexplained whooshing or ringing in her ears—but only briefly. After a few minutes, however, she realized the sound wasn't easing up. She started to panic.
“I remember getting in the shower, every nerve in my body on fire, the sound of running water masking the sound,” Meny said. “Rapid thoughts shot through my head—Was it gone now? What about now? I remember plugging my ears with my fingers, praying that I wouldn't hear the noise. And of course, I always did.”
Hours later at the college's student health center, a physician told the young woman she was experiencing tinnitus, insinuated that she was to blame because she had been listening to music prior to symptom onset, and gave a blunt prognosis: “The tinnitus might go away on its own, or it might continue for the rest of your life.” Left unaddressed was the fact that Meny disliked loud music and therefore kept her earbuds’ volume low. Meny's growing distress went unacknowledged as well.
In the audiologist and ENT visits that followed, no one asked how Meny was coping. Had they done so, they would have learned her anxiety level was through the roof. Not helping matters was Meny's amateur research into her new, mysterious diagnosis, which involved “extremely dark online forums where people talked about friends with tinnitus who committed suicide and how tinnitus was so debilitating suicide seemed like the only option,” Meny recalled. “I was not, and am not, suicidal in any way. But seeing those comments made me so terrified—I worried those stories would become my fate.”
SELF-HARM AND SUICIDE
In the presence of tinnitus, a person's mental health can be precarious. Whether mental illness contributes to the development of burdensome tinnitus or is the eventual result of struggling to cope with incessant sound no one else can hear, anxiety, depression, and behavior disorders are believed to affect up to three-quarters of people living with severe tinnitus, according to the American Tinnitus Association (ATA).1 As Meny was horrified to discover, tinnitus also increases the risk of suicidal and self-harm ideations.2
In recent months, new studies have further detailed the association between tinnitus and attempted suicide. A large, population-based study in Sweden published in JAMA Otolaryngology-Head & Neck Surgery found that severe tinnitus was linked to heightened suicide attempts in women, but not in men.3 Researchers wondered if different pathophysiologic mechanisms may be occurring in each sex; they recommended that future studies probe the possibility in more depth.
Another study—this one in the American Journal of Audiology—found parental mental illness, such as anxiety, depression, and anger, during childhood was associated with significantly increased risk of suicidal and self-harm thoughts in adults with tinnitus.4 In the study conclusion, researchers advised hearing care providers to screen for such ideations in patients, “especially for those with symptoms of depression and a childhood history of parental mental illness.”
Yet talk about the mental health burden of tinnitus remains troublingly absent in many hearing professionals’ offices.
“It needs to be something audiologists aren't afraid of. Mental health is not a taboo subject,” said Melissa Wikoff, AuD, the owner of Peachtree Hearing in Atlanta, GA. “Sometimes we think the practice of audiology is not life or death. But sometimes with tinnitus, it really can be.”
LISTEN, THEN VALIDATE
Even when the stakes aren't as high, an audiologist's intervention—or referral, when appropriate—can profoundly improve the life of someone with tinnitus. Technological interventions can range from using hearing aids to correct an associated hearing loss (and in some cases, ease an overworked brain that, Wikoff mused, seemingly compensates for hearing loss by generating a phantom sound to stimulate the auditory nerve) to wearing musician earplugs. Sound generators that produce white, pink, or red noise to mask the tinnitus are another commonly used option, although a 2018 review published in JAMA Otolaryngology—Head & Neck Surgery warned against the “seductive short-term solution” of unstructured acoustic noise. In the long run, the authors wrote, white noise exposure appears to “undermine the functional and structural integrity of the central auditory system and the brain more generally.”5
Sometimes a combination of approaches works best. Other times, tinnitus retraining therapy is the way to go.
“It's different for everyone,” said Wikoff. “There's no magic pill, no one-size-fits-all.”
Regardless, throughout the process of assessments, examinations, and audiologic interventions, experts say hearing care professionals have two consistent duties to patients: to listen and to validate.
“I believe every audiologist, every general practitioner, and every ENT should know enough about tinnitus and tinnitus management to be able to listen, give hope, and refer to an audiologist or a mental health professional educated in proper tinnitus management,” said Jeannie Karlovitz, AuD, CCC-A, F-AAA, an audiologist who specializes in tinnitus at Advanced Hearing Solutions in, Exton, PA, and a member of the ATA's Tinnitus Advisors Program. (People with tinnitus, as well as their health care providers, can call the advisors program at 800-634-8978 for help with tinnitus management or referral to a local tinnitus care provider.)
“Audiologists should be aware that patients with tinnitus are potentially fragile emotionally, especially during the early months following onset of tinnitus,” advised Caroline J. Schmidt, PhD, a clinical psychologist at Yale Medicine in New Haven, CT, who helped develop the progressive tinnitus management program used nationwide by the Veterans Health Administration. “The impact of tinnitus differs among people. Some people have no emotional response to it at all. Other people find it to be very distressing.”
That's why when Wikoff greets a patient for an initial tinnitus appointment (for which she typically books two hours; Karlovitz, three hours), she begins with an open-ended question, “What brings you in to the office today?”
Then, she listens.
“I pay attention to what they are saying. I don't look down at a clipboard or my computer and write notes. I look at the patient,” she said. “You need to demonstrate empathy, and let them know they're not alone, they are not the only person who has had this, and they came to the right place. There are treatment options available, and it's going to be OK.”
Audiologic and tinnitus evaluations usually follow, after which Wikoff may try out various interventions to see how each affects the tinnitus. After detecting a mild hearing loss in one patient recently, she fitted her with hearing aids and was astounded by the changes at a check-up two weeks later. The woman's score on the Tinnitus Reaction Questionnaire had plummeted from 69 to 19; her tears had transformed into smiles.
Unfortunately, not every patient experiences such quick improvement. For some, the process spans months, sometimes years. And at this point in time, tinnitus is still without a definitive cure. Although patients deserve to know this difficult truth, it needs to be delivered gently—and completely. The full reality is that multiple strategies are available to allow people to successfully manage tinnitus.
“We can't ever promise that the tinnitus will go away,” said Karlovitz. “But what I do say is, ‘The way you feel right now is not the way you are going to feel in a few months after you start implementing some of these strategies.’”
MANAGING MENTAL BURDEN
If conversation or patient questionnaires indicate someone is in distress or dealing with thoughts of self-harm or suicide, referral to a mental health provider should be prompt. Audiologists with tinnitus specialties often have a network of psychiatrists, psychologists, and/or licensed social workers they can refer to when they think a patient would benefit from cognitive behavioral therapy, mindfulness-based stress reduction, or other psychotherapies. Patients with less severe mental health burdens, meanwhile, can benefit from anxiety-reducing strategies taught right in the audiology office.
“Each audiologist has a different skill set and will refer to mental health at different points,” said Schmidt.
Karlovitz coaches her patients in several mental health strategies to ease the effects of tinnitus:
Acceptance: The strategy of acceptance requires understanding, so the audiologist begins with tinnitus education, including causes of tinnitus and how the condition triggers emotions in the brain. At its basis, tinnitus is just a sound, neutral in itself, and Karlovitz encourages patients to focus on that truth.
Thought restructuring: Changing negative thoughts into neutral or positive thoughts can empower patients to move forward with fewer stressful, anxious, or depressive symptoms. Thought restructuring includes reframing all-or-nothing thinking (“This tinnitus is so awful, I'm never going to sleep again”) to reality-based reasoning (“The fact is eventually sleep does come, and some nights I do get some good sleep”). Karlovitz challenges patients to create a mantra to repeat to themselves during difficult times. “One man I'm working with just this week texted me his mantra: ‘It's time to tame my tinnitus,’” she said. “I loved that.”
Relaxation and sleep hygiene: To set the stage for better sleep at night (and greater emotional stability during the day), Karlovitz recommends sound enrichment such as white noise machines to reduce awareness of tinnitus that's more troublesome in quiet. Avoiding alcohol, caffeine, and electronic devices before bed, fully darkening the bedroom, and setting a comfortable nighttime temperature also support sleep. For people who experience nighttime worries, writing them down before bedtime can help still the mind. Finally, deep breathing and progressive muscle relaxation exercises (apps are available that guide the listener through the process in about 20 minutes) can help too.
Continuing enjoyable activities: Although the lure of isolation can be tempting, Karlovitz encourages patients to pursue hobbies and interests amid tinnitus since isolation can make anxiety and depression worse. By staying connected to the people and activities they love, patients maintain links to valuable sources of happiness and fulfillment.
“When people use a combination of these management strategies, something happens. Positive thoughts start to come,” said Karlovitz. “And as they continue to practice the strategies, something changes. Eventually, they come back and say, ‘The tinnitus is not bothering me as badly as it did before. I can move forward with this.’”
Realizing she needed more help, Meny eventually found a therapist to help her navigate her anxiety.
Today she is a 26-year-old reporter and writer in Seattle. She still lives with tinnitus, but it doesn't affect her hearing. She still lives with anxiety too, but she's learned to manage it. She copes with the condition by taking care of herself: eating well, exercising, and limiting coffee. Furthermore, she's found meaning in her experience by turning it around and becoming an advocate for tinnitus awareness.
“I never want anyone to feel as alone or hopeless as I did,” she said.
During a visit to a new primary care provider just weeks ago, Meny heard something she had never heard before.
“When I told him I had tinnitus, he asked me how I was coping with it,” she said. “It was a breath of fresh air, about five years too late.”
Thoughts on something you read here? Write to us at HJ@wolterskluwer.com