A scientific cognitive-behavioral model of tinnitus: novel conceptualizations of tinnitus distress

Abstract

The importance of psychological factors in tinnitus distress has been formally recognized for almost three decades. The psychological understanding of why tinnitus can be a distressing condition posits that it becomes problematic when it acquires an emotive significance through cognitive processes. Principle therapeutic efforts are directed at reducing or removing the cognitive (and behavioral) obstacles to habituation. Here, the evidence relevant to a new psychological model of tinnitus is critically reviewed. The model posits that patients' interpretations of tinnitus and the changes in behavior that result are given a central role in creating and maintaining distress. The importance of selective attention and the possibility that this leads to distorted perception of tinnitus is highlighted. From this body of evidence, we propose a coherent cognitive-behavioral model of tinnitus distress that is more in keeping with contemporary psychological theories of clinical problems (particularly that of insomnia) and which postulates a number of behavioral processes that are seen as cognitively mediated. This new model provides testable hypotheses to guide future research to unravel the complex mechanisms underpinning tinnitus distress. It is also well suited to define individual symptomatology and to provide a framework for the delivery of cognitive-behavioral therapy.

Keywords: belief; distorted perception; negative thoughts; safety behavior; selective attention; tinnitus.

Figure 1

A cognitive model of tinnitus distress. Representation of the novel cognitive-behavioral model of tinnitus distress. Tinnitus provokes distress when a person holds overly negatively thoughts about it. These negative thoughts provoke arousal and emotional distress and motivate maintaining factors such as selective attention, monitoring, and counterproductive safety behaviors. These processes result in the patient overestimating the intensity and complexity of tinnitus, i.e., patients gain a distorted perception of tinnitus. Distorted perception is also fueled by overly negative thoughts of tinnitus. A number of feedback loops are involved: selective attention and monitoring leading to greater detection of tinnitus, to further negative appraisal; distorted perception of tinnitus leads to further negative appraisal and we tentatively hypothesize that negative appraisal contributes to distorted perception. In many cases, safety behaviors adopted to cope with the perceived threat inadvertently maintain or exacerbate existing worry and in many cases also directly alter the detection of tinnitus, e.g., by manipulating environmental sounds. Beliefs about tinnitus also fuel negative thoughts. Such beliefs are based on experience of tinnitus in others or derive from general beliefs about health, the self, or the world. Both conscious and involuntary processes are involved but the model emphasizes conscious processes as these constitute the main therapeutic targets.