Taming tinnitus
New insights find connection between this common condition and PTSD
By Claire Kowalick
It can manifest as a low- or high-pitched tone — a squeal, buzz, roar, chirp or click seemingly coming from one or both ears or in the head. It can dissipate within seconds or be continually present; barely discernable or as loud as a freight train.
Many people live with tinnitus and consider it to be a minor annoyance, but for up to 20% of sufferers, the condition can be bothersome enough to impair daily function.
John Moring, PhD, assistant research professor in the Department of Psychiatry and Behavioral Sciences at The University of Texas Health Science Center at San Antonio, has lived with tinnitus for as long as he can remember. Moring was a gymnast while growing up and thinks his tinnitus could be related to head or neck injuries he received during that time. While he is lucky enough to be part of the 80% of people only mildly hindered by the condition, he wondered if there was a way to help others who are truly suffering.
PTSD could affect perceived impact
“Tinnitus could manifest as a result of acoustic trauma, but neurobiologically, we’re not seeing main alterations within the auditory cortex,” Moring said. “It’s not necessarily a dysfunction within a person’s auditory pathways. Some theories suggest that tinnitus is a dysfunction related to gating mechanisms, resulting in the brain’s lack of ability to appropriately screen out information you otherwise would not be attending to. If this gating mechanism fails, we have more information coming in, and the brain doesn’t know how to process that, so it is interpreted as tinnitus, potentially.”
In a research study, Moring used an Implicit Association Test to determine participants’ responses to positively or negatively valenced words paired with tinnitus-related words. A quicker response time to tinnitus-related words, when paired with negative words, was observed when individuals were primed to think about their own tinnitus. This finding suggests an automatic and negative view that individuals often from the same study indicated that acceptance of tinnitus can help alleviate tinnitus-related distress.
“If you are less willing to accept your tinnitus as it is, then the more distressed you are going to be,” Moring said.
During his clinical internship, Moring treated veterans suffering from post-traumatic stress disorder (PTSD), and he observed that among veterans with PTSD, those who concurrently had tinnitus were more hyper-reactive and had elevated PTSD symptoms compared to those with PTSD only.
“I wondered if there was a connection between tinnitus and PTSD, in particular, and whether this particular combination serves to negatively impact functional outcomes among veterans,” Moring said.
When Moring began working at the health science center 11 years ago, there were only three studies that considered the connection between tinnitus and PTSD. One study looked at Cambodian refugees from the Khmer Rouge rule and found a strong connection between PTSD and increased tinnitus distress. This study demonstrated that flashbacks of participants’ trauma were very often associated with prominent tinnitus and that those with tinnitus had heightened levels of catastrophic thoughts, compared to those with PTSD without tinnitus.
Not better together
A separate study examining U.S. veterans found that individuals with tinnitus and PTSD fared worse functionally than individuals with PTSD and any other psychological health comorbidities, such as depression or anxiety.
“There is something about these two conditions that serves to limit individuals’ functioning in life. Those with co-occurring PTSD and tinnitus may not be as happy or engaged in everyday sorts of activities, may find it more difficult to relax and engage in social activities and can find themselves angrier and more irritable. This combination really does impact their quality of life,” Moring said.
Understanding more about brain functioning among those with both PTSD and tinnitus can help clarify why these two conditions are particularly deleterious. Moring applied for and was granted a Mentored Research Career Development (K12) award to work with his mentor, Peter Fox, MD, director of the university’s Research Imaging Institute, to learn about neuroimaging methods and techniques (read more about the pioneering brain imaging project Fox created on page 29).
Moring also learned how to conduct neuroimaging coordinate-based meta-analyses based on all available data from published findings. While tinnitus seems like an auditory condition, it stems from a neurological dysfunction. Through a tinnitus neuroimaging metaanalysis, Moring learned the auditory cortex is not the primary region involved in the disorder. Instead, main regions associated with tinnitus are located within the default mode network, an area of the brain that is more active when a person is at rest.
The region is also partially involved in selfgenerated thoughts such as daydreaming, autobiographical information and future planning. When he relaxed the statistical threshold of the tinnitus meta-analysis, Moring found additional brain regions involved with tinnitus, some of which are also involved in PTSD.
One treatment for both?
Another goal of Moring’s K12 study aimed to test whether treatment of PTSD would also improve tinnitus-related stress. Findings demonstrated that while PTSD symptoms declined significantly due to treatment, declines in tinnitus-related distress did not reach statistical significance. However, he observed large effect sizes, indicating a relationship between PTSD treatment and improvement in tinnitus distress. These findings also provide justification for additional research regarding the treatment of both conditions simultaneously.
Moring is now collecting neuroimaging and audiometric data from individuals with both tinnitus and PTSD, healthy controls without either condition and veterans and active-duty service members with either tinnitus or PTSD. With funding from the National Institute of Mental Health, Moring aims to find the neurobiological similarities and differences between these groups. Data from those with both PTSD and tinnitus and those with only tinnitus was entered into a spatial parametric map to show brain activation specific to each condition, as well as regions that share similar activation.
“With tinnitus you have the psychological sequalae-like concentration problems, sleep issues, maybe anger and irritability that are overlapping with PTSD,” Moring said. “We can now see this overlap neurobiologically, which may result in additive psychological effects and may explain worse functional outcomes among individuals with co-occurring disorders.”
“Some theories suggest that tinnitus is a dysfunction related to gating mechanisms, resulting in the brain’s lack of ability to appropriately screen out information you otherwise would not be attending to. If this gating mechanism fails, we have more information coming in, and the brain doesn’t know how to process that, so it is interpreted as tinnitus, potentially.”
Testing crossover effects
Also in the works is a new randomized, crossover clinical trial looking at veterans with tinnitus and PTSD. The study will treat veterans with PTSD using cognitive processing therapy, followed by cognitive behavioral therapy for tinnitus.
Alternatively, participants may be randomized to receive cognitive behavioral therapy for tinnitus followed by cognitive processing therapy for PTSD. Moring said they aim to determine if PTSD treatment could improve tinnitus, possibly to the extent that the second protocol is unnecessary.
“When these symptoms co-occur, and we see that in the brain, that could be the reason these individuals are more impaired. It is an additive effect,” he said.
Moring hypothesizes a calming of the system for PTSD could also relieve some tinnitus-related distress.
“I’m thinking it is a unidirectional relationship where PTSD, the psychiatric distress, is serving to inflame the annoyance and perceived loudness of the tinnitus,” Moring said.
Because tinnitus is closely tied to individuals with hearing loss, Moring said audiologists that screen for tinnitus should also consider checking for mental health conditions like depression, anxiety and PTSD.
“If that is also contributing to the tinnitus-related distress, maybe it’s going to be more efficient to address the psychological side of things first, and in doing so, some of those skills automatically apply to help reduce tinnitus-related distress,” he said.
Moring uses the biopsychosocial model to help conceptualize how these disorders are interacting specific to each person. By doing so, he aims to provide individuals with the skills and techniques to promote a more balanced way of thinking about stressful situations and to experience natural emotions.
Moring also aims to change the relationship individuals have with their tinnitus, so that eventually, instead of tinnitus feeling like a large rock in their shoe that impairs functioning, it is a tiny pebble that they notice only occasionally.
9 Facts About Tinnitus
1. According to the National Institute for Deafness and Other Communication Disorders, tinnitus is the perception of a sound in the ears that does not have an external source. It is common, affecting between 10% to 25% of the population.
2. Tinnitus can affect children and adults, can be transient or intermittent and can be an unrelenting chronic condition.
3. There are multiple possible causes of tinnitus, including exposure to loud noises, hearing loss, head or neck injuries, or taking certain medications. In some cases, the cause of tinnitus is unknown.
4. Tinnitus sounds and duration manifest differently for each person. It can be perceived as a ringing, buzzing, roaring, hissing, high- or low-pitch tone, blowing, whistling, humming or sizzling. Some describe it like the buzz of cicadas, musical notes or the wave-like woosh when you put your ear to a seashell. Those more affected by tinnitus tend to have a variety of sounds that change day to day.
5. Up to 33% of military personnel experience tinnitus, especially those exposed to acoustic trauma from weaponry and explosive devices like IEDs and RPGs or proximity to aircraft carriers.
6. Up to 90% of those with tinnitus have some form of hearing degradation.
7. Hearing aids for those with hearing loss can mitigate tinnitus by boosting the ability to capture sound in the area, thereby drowning out the tinnitus.
8. Certain medications, or withdrawal from them, can exacerbate tinnitus.
9. Comorbidities like PTSD could prevent habituation to tinnitus sounds, possibly due to auditory-based hypervigilance.
