ACE Your Reactive Tinnitus
Some people report that their tinnitus changes character on exposure to specific external sounds, then returns to its usual profile at a later time. These changes may involve an increase in tinnitus volume, frequency, or a change in the quality of the tinnitus sound (example, from a hiss to a whistle). While poorly documented in the professional literature, within the patient community this pattern is commonly called reactive tinnitus. The external sounds that lead to the changes are called triggers. It’s important to note that for reactive tinnitus the term trigger refers only to external sound, not diet, posture, etc.
The changes in tinnitus that comprise a reactive pattern may occur during or after exposure to the trigger. They may resolve quickly or persist for minutes, hours, and in some cases days before tinnitus returns to baseline. Some people report that their tinnitus seems to “compete” with the external sound, meaning that the tinnitus volume increases as the external volume increases. This can make sound enrichment challenging and potentially ineffective as a coping tool.
There are no scientific studies of reactive tinnitus. However, in one general survey, 42% of participants reported that their tinnitus was “made worse by noise.”
Is Your Tinnitus Really Reactive?
It’s important to clarify that what you’re experiencing are objective and not subjective changes in your tinnitus. For one, anxious attention to tinnitus (hypervigilance) can affect the perceived nature of tinnitus. For example, stress and anxiety increase hypervigilance, which can result in tinnitus appearing louder when in fact the objective volume is unchanged. You may fear that exposure to louder settings will make your tinnitus worse. The anxiety then increases your hypervigilance, which makes your tinnitus subjectively seem worse. As we’ve discussed, contrast effects can cause subjective fluctuations in tinnitus volume. On transitioning from a loud to a quiet setting, your tinnitus may subjectively seem louder.
It is also common to mistake variable tinnitus for reactive tinnitus. What sets reactive tinnitus apart from variable tinnitus is the presence of a clear external sound trigger that initiates the changes. With variable tinnitus, the volume or character of the sound instead fluctuates randomly. Variable tinnitus appears to be much more common than reactive tinnitus, with at least 70% of people with tinnitus reporting random fluctuations. It’s common for people with tinnitus distress to search for external “triggers” for these fluctuations, or “spikes” even if there aren’t any. Along with the various debunked dietary factors, they’ll look to external sounds. If your tinnitus happens to be louder on an evening following attendance at a loud event, you may mistakenly believe the event led to the increase in your tinnitus.
Reactive Tinnitus can Lead to Phonophobia
A common consequence of reactive tinnitus is phonophobia, an exaggerated fear of external sounds that you believe could make your condition permanently worse. Situations where the feared sounds occur are anticipated with great anxiety and either avoided entirely or endured with great discomfort. Exposure may be followed by obsessive worry that you’ve made your condition permanently worse and a renewed commitment to avoid similar situations in the future. Persistent avoidance can result in secondary problems, as you miss out on more and more of life. And avoidance of sound removes the opportunities you and your alarm brain need to adapt and habituate to the tinnitus.
Reactive Tinnitus and Habituation
People often assume that one cannot habituate to reactive tinnitus, that the fluctuation in volume will prevent the brain from calming down and screening tinnitus out. This belief is absolutely not true. In fact, studies show that people habituate to the full range of tinnitus patterns. You may have evidence of this from your past experience, as you have likely already habituated to an external sound that varies in loudness. Imagine hearing a common motor that goes on and off, like a refrigerator or air conditioner. At first you may have been distracted by the volume fluctuations, but after a while, if you notice them at all, it’s a mere momentary awareness triggered by the shift from quiet to loud, that disappears as the motor hums on.
What You Can Do
As I said, the usual CBT strategies will apply to reactive tinnitus, with a few exceptions and emphases described below:
Careful Thinking
Challenging the false belief that reactive tinnitus is immune to habituation is the first step toward your recovery. In your thinking, it’s important to understand two facts: 1) the changes associated with reactive tinnitus are generally not permanent, and 2) over time, people can habituate. Habituation can be expected to follow the typical course, and all the usual CBT skills apply.
Furthermore, habituation to reactive tinnitus, compared to, say, variable tinnitus, may actually be easier, as the changes in reactive tinnitus tend to be predictable. We know that coping and habituation are enhanced by familiarity and predictability. The more familiar and predictable your tinnitus, the easier it is to cope, as knowing a louder period is coming can help you prepare emotionally for the challenge. And as tinnitus becomes the new normal, business as usual, your alarm brain will more readily recategorize it as unimportant.
To increase familiarity and predictability of reactive tinnitus, it may help to get a clear understanding of what sounds trigger the changes and how long the changes last, what I call your “reactive curve.” Having this understanding could help with coping and habituation. By reactive curve, I mean the course your tinnitus takes on and after exposure to the various triggers. Ask yourself: What sounds trigger the changes? How does my tinnitus change? And how long do the changes last? Answering these questions can help you identify your reactive curve. This exercise can help to establish predictability and reassure you that your tinnitus is not getting permanently worse. (Note: It’s the only time I will ever encourage you to monitor your tinnitus against external factors!)
With most tinnitus, careful thinking challenges the false belief that if you just keep trying you can eventually find ways to gain control over your tinnitus. However, if your tinnitus is truly reactive to specific external sounds, this may not apply, as you can keep the volume lower by avoiding reactive triggers. But as we’ve seen, this control comes at a considerable price, as avoidance robs you of a life worth living. If your goal is habituation, then you must commit to facing and accepting the fact that your tinnitus will fluctuate (Let Tinnitus Do What Tinnitus Does).
Mindfulness: Practice Letting Tinnitus Do What Tinnitus does
Mindfulness is the practice of doing just that: allowing tinnitus to be exactly as it is, without getting pulled into thoughts and urges to get control over it. I’m only emphasizing here what is clearly stated in my Mindfulness for Tinnitus program, and all the usual mindfulness skills apply.
Self-Guided Sound Therapy
Sound enrichment is one strategy that may work differently for reactive tinnitus. Sound enrichment is the use of carefully selected external sound to help soften your perception and distract you from tinnitus. For some people, sound enrichment results in tinnitus becoming louder or otherwise changing in ways that have the opposite of the desired effect by increasing tinnitus awareness and distress. This can be a considerable problem for audiologist-guided sound therapy approaches like TRT.
If it occurs for you, please make sure you’ve thoroughly reviewed the Self-Guided Sound Therapy section (article). Make sure you’ve made a good enough attempt to find sounds that help, that you’ve given it enough time, and that you’ve have applied the mindfulness listening through skill. If after this you still can’t find sounds that help blend and distract, it’s ok. Considerable research suggests that sound enrichment is unnecessary for habituation. Just double down on your other CBT skills, careful thinking and mindfulness, and keep the focus on accepting your tinnitus, fluctuations and all, and rejoining your life.
Take Courageous Action to Rejoin Your Life
Use this strategy to gradually expose yourself to the sounds and situations that trigger changes in your tinnitus. This is particularly important to reverse any developing phonophobia. By taking courageous action to face the triggers you’ll gradually adapt and habituate to the reactive curve of your tinnitus.