10/24/2016. Jennifer J. Gans, PsyD Clinical Psychologist MindfulTinnitusRelief.com, LLC. Presenter Disclosure. Goals for Today s Talk

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1 MINDFULNESS BASED TINNITUS STRESS REDUCTION (MBTSR): Tinnitus, Brain Functioning, & Mindfulness Jennifer J. Gans, PsyD Clinical Psychologist, LLC Presenter Disclosure Dr. Jennifer Gans has received a grant for the research and research results discussed in the presentation. Studies discussed in the course are based on research conducted at UCSF. Dr. Gans has intellectual property rights for material presented/discussed in the presentation: she is the CEO & Founder of which has non profit and for profit status. This course focuses on Mindfulness Based Tinnitus Stress Reduction (MBTSR), with particular attention to the presenter's program,. Goals for Today s Talk Tinnitus Reviewed What Is Happening Inside the Tinnitus Brain De-Mystifying Meditation & Mindfulness How Meditation & Mindfulness are tools to change the Tinnitus Brain MBTSR Research & Findings Development of Audiology & Psychology Working Together for Effective & Balanced Tinnitus Care 1

2 Tinnitus Reviewed Perception of Tinnitus Bother: Psychoacoustic Properties of Tinnitus US Tinnitus Demographics 2-20 db SL 2 3 M Debilitated 2-20 db SL 2-20 db SL M Significant Problem 33 M Not Bothered (Jasterboff 1993) Tinnitus: An Imbalance in the Brain s Threat-Appraisal System The Sound Sensitivity Disorders of tinnitus & hyperacusis have been described as a: dysfunctional valuation process and abnormal assignment of negative meaning to a neutral stimulus (Rauschecker et al 2015) 2

3 Questions To Ponder: Why are some people bothered and others non-bothered by tinnitus? The Tinnitus Gordian Knot: Is it tinnitus that is the problem or is it the emotions, memories, thoughts, feelings, beliefs, perspectives, stories etc about the tinnitus that are the problem? Tinnitus Gordian Knot What Might be Happening in the Tinnitus Brain Pre Frontal Cortex (conscious) Brainstem (subconscious) Limbic (subconscious) 3

4 Tinnitus: From Reaction to Response Between every stimulus and response is a space. And within that space lies our freedom & choice. -Victor Frankel What We Know From Other Fields of Science Cortical Areas Thicker in Meditators 1. Brain areas (mpfc) are thicker in practitioners of Insight meditation than control subjects who do not meditate. 2. Graphs show age and cortical thickness of each individual. (Lazar et al., 2005) Prefrontal red = control subjects blue = meditators 4

5 Tinnitus Boot Camp: Strengthening the Awareness Muscle We use the torque of repetition to build the attention/awareness muscle to modify our brain With repetition the associated neurons wire, fire, grow, & strengthen (neuroplasticity) Mindfulness: Not Just for Tinnitus Efficacy with a Range of Illnesses Chronic Pain (Grossman et al., 2007) Sleep & Dietary Problems (Gross et al., 2011) Anxiety (Hofmann et al., 2010) Depression (Mason & Hargreaves, 2001) Stress (Shapiro et al., 2005) PTSD (Smith et al., 2011) Fibromyalgia (Grossman et al., 2007) Chronic Fatigue (Surawy et al., 2005) Multiple Sclerosis (Grossman et al., 2010) Psoriasis (Kabat-Zinn et al., 2003) De-Mystifying Mindfulness & Meditation 5

6 Mindfulness Defined Mindfulness is paying special attention on purpose in the present without (clinging to) judgments to the unfolding of experience, moment by moment. ~ Jon Kabat-Zinn Mindfulness: Being With & Approaching our Experience Requires a special kind of awareness Curiosity Openness Acceptance Compassion (Loving-Kindness) The Brain as Symphony 6

7 How we hold tinnitus makes all the difference Tinnitus Inside Your Brain While Meditating ~ Pain in life is inevitable; Suffering is optional ~Buddha 7

8 MBTSR: From Anecdote to Empirical Data A Growing Body of Research Specifically Investigating Mindfulness & Tinnitus Sadlier, et al (2008) Phillippot, et al (2012) Gans, et al (2013) Gans, et al (2015) Roland, et al (2015) Mindfulness Based Tinnitus Stress Reduction (MBTSR) What the Research Shows 8

9 MBTSR Course Design 8 weeks in length 2 Hour Class per week Tinnitus Education Mindfulness Lesson Instructor led meditations, gentle yoga, mindful movement Discussion Questions Skill Building Activities, calendars, and readings Home Practice: 30 minutes per day, 6 days/week A Day-Long Mindfulness Retreat between the 6 th & 7 th week Mindfulness Based Tinnitus Stress Reduction: Pilot Study (Gans, O Sullivan, & Bircheff 2013) Subjects: 8 tinnitus patients who had previously received Tinnitus Counseling (standard of care) at the UCSF Audiology Clinic Pre- & Post assessments 30 minutes of Home Practice daily Post-Intervention Feedback Form (PIFF) administered at the end of the last class Tinnitus Handicap Inventory (THI) administered at 12-Month Follow-up (Gans, Cole, Greenberg 2015) MBTSR Measures Primary outcome measure: Tinnitus Handicap Inventory (THI) Secondary outcome measures: Tinnitus Visual Analogue Scale (VAS) (a measure of tinnitus annoyance) Tinnitus Percent Awareness Scale Hospital Anxiety and Depression Scale (HADS) SF-36 Symptom Checklist-90-Revised (SCL-90-R) Five Facet Mindfulness Questionnaire (FFMQ) Qualitative measure 9

10 Summary of MBTSR Findings (Gans et al., 2013) Decreased Tinnitus Handicap & Bother Decreased Depression Decreased Anxiety Increased Mindfulness Increased Quality of Life Tinnitus Symptom Severity & Awareness Pre-, Post, and 12-Month Follow-Up Mean Scores Pre-, Post, and 12-Month Follow-Up Intervention Score Differences with Effect Sizes Pre-MBTSR Post-MBTSR 12-Month FU Effect Size Measure Mean (SD) Mean (SD) Mean (SD) (Cohen s d)* THI (15.22) 39 (21.8) 23.6 (16.8).69 VAS 59 (24.87) (24.26).99 Tinnitus Awareness 60 (33.7) (32.49).64 FFMQ Non-Judge Observing Non-Reactivity Describe Acting with Awareness 28 ( (5.64) (4.81) (5.78) 28 (6.57) (6.94) (3.92) 23 (9.44) (5.53) (4.4) SF-36 Social Functioning Mental Health Vitality 39.5 (10.35) (11.21) (9.1) 49 (46.3) (9.32) (6.94) * Effect Size (ES) rather than levels of significance were reported due to a small sample size. HADS 15.5 (6.46) (7.23).30 SCL-90-R.52 Depression 66.5 (12.3) (24.44).62 Phobic Anxiety (13.31) (21.77) Somatization Anxiety (14.75) (12.57) (23.5) (23.95)

11 Tinnitus Handicap Inventory (THI) n=7 Tinnitus Handicap Inventory (THI) Qualitative Measures: What participants are saying 11

12 Overall Perception Shift: Qualitative Findings Tinnitus doesn t seem like a terrible curse anymore. It s sometimes annoying now but not insurmountable. I have come to see it (tinnitus) now as just another sensation, typically unpleasant, rarely neutral, never pleasant but I try to be aware without judging. What Participants Are Saying: Qualitative Findings Changes in Sleep: I am sleeping in a more regular pattern now. When I take medication to sleep, I m taking half instead of the full dose. What Participants Are Saying: Qualitative Findings Changes in Symptoms of Depression: I can go into the ringing without going towards depression. 12

13 What Participants Are Saying: Qualitative Findings Improved General Functioning: I am adapting the mindfulness process into my daily life. It has greatly helped me, not only to cope with the tinnitus but also with my relationships, communication, patience and anger-management. Yes, it has been a big commitment time-wise, but so worth it. What Participants Are Saying Recent Quote from a Participant of the course: It s funny. After just a few weeks of starting the course, I am noticing that my tinnitus doesn t bother me as much anymore. And I m getting along better with my husband. The next phase 13

14 The first-ever selfadministered online skill-building course of its kind for learning how to live comfortably with tinnitus : 8-Week Online Course MBTSR World-Wide with Online Access Low Cost Desktop, laptop, Tablet, smartphone accessible Reaches those with limited access to tinnitus care Weekly classes at participant s convenience Patients can self-refer Privacy Automated reminders can be sent to encourage treatment compliance Puts Tinnitus Healing back into the hands of the patient : Activities Advanced and Up-to-Date Tinnitus Information and Education 14

15 How we help our patients hold tinnitus makes all the difference Tinnitus Thank You Questions? 15

16 tech TOPIC // Tinnitus Mindfulness Based Tinnitus Stress Reduction: Unraveling the Gordian Knot of Tinnitus By Jennifer J. Gans, PsyD The Mindfulness Based Tinnitus Stress Reduction (MBTSR) program focuses on helping people uncover their own internal resources toward a reinterpretation of tinnitus. At this point, no universal cure for tinnitus has been identified. This news is a tough pill to swallow for the millions of people around the world struggling with bothersome tinnitus. But with continued inquiry, creativity, and dedicated study over the past few decades, there are now several tools from the fields of hearing instrument technology, audiology, medicine, and psychology to guide people in their effort to shift their experience of tinnitus from bothersome to non-bothersome. Education about what tinnitus is (and isn t) in conjunction with a thorough hearing assessment by an audiologist and appropriate hearing specialist is a good place for someone bothered by tinnitus to start. For those who continue to be distressed by tinnitus, discoveries into the mind s ability to re-perceive tinnitus bother in new, more positive ways is an important next step. Recent research has shown that mindfulness-based approaches to living with tinnitus are effective in helping people modify their perception, leading to reduced tinnitus bother, less emotional struggle, and a greater sense of wellbeing. Specifically, Mindfulness Based Tinnitus Jennifer Gans, PsyD, is a clinical psychologist specializing in the psychological impact of deafness and hearing in her private practice in San Francisco. She is the lead psychologist for UCSF Hearing Loss Center, and holds the position of psychologist and researcher at the VA of Northern California. Dr Gans is also the CEO/Founder of, the online version of the 8-week MBTSR course. Stress Reduction (MBTSR), 1,2 an 8-week skillbuilding program developed and researched at University of California San Francisco (UCSF), teaches participants how to develop more healthful and positive ways of relating to the unpleasant sensation. MBTSR includes indepth tinnitus education and mindfulness skill building. Each week s class integrates elements of deep breathing, gentle yoga, relaxation, and meditation to help people develop new, more effective ways to relate to the experience of tinnitus and stress in their daily lives. There are many approaches to the management of tinnitus few of which are mutually exclusive. Often, management tools can be used independently or in conjunction with treatments to gain maximum benefit, depending on the individual with tinnitus. MBTSR is one of these management tools and will be discussed in the following paper. Tinnitus is a Riddle Wrapped in a Mystery Inside an Enigma Some of the habitual thoughts we develop around tinnitus can prevent our mind s ability to change our habitual reaction to the sound. The person with chronic bothersome tinnitus rarely experiences the unpleasant sensation of tinnitus in isolation. Almost always, the tinnitus sensation is wrapped tightly in a cascade of thoughts, judgments, memories, fears, emotions, sadness, regrets, beliefs, and feelings about past, present, and future experiences living with this chronic symptom. Tinnitus gets wrapped in a Gordian Knot of our mind s own creation. A Gordian Knot is a metaphor for an intractable problem that requires thinking outside the box to solve. This is no small task and requires self-discipline, focus, and patience to master. The skill proposed and taught in a mindfulness-based approach to tinnitus management begins with bringing awareness to our habitual thoughts and beliefs about tinnitus. We come to realize that many of these thoughts, judgments, and beliefs are based on how we wish things could be rather than finding creative solutions for living with tinnitus with ease in the present. Instead it is common to hold on tightly to a narrative of how bad life will be if tinnitus persists or how we somehow did something to cause our tinnitus fate. Rather than experiencing the tinnitus as a bare body sensation, tinnitus often gets wrapped up in a whirlwind of thoughts and beliefs that keep us stuck in stories from the past and predictions for a bleak future. These past and future strivings only serve to cloud our ability to see tinnitus as a present moment body sensation, and we limit our options for choosing healthful and creative ways of managing tinnitus in the moment. Bringing awareness to how we may, in fact, be helping to create our own suffering our own Gordian Knot is not an easy task. Much like going to the gym to build a muscle, a personal trainer can guide us, but ultimately we have to do the heavy lifting to reach our desired results. However, with practice, we can train our minds, rewire old thinking habits, modify our behaviors and reactions, and ultimately, learn to live with tinnitus with greater ease. The intersection of tinnitus and mindfulness. Tinnitus is most often related to hearing loss, especially that caused by noise damage or head injury. It affects approximately 10% of adults in the United States and an estimated 260 million people globally. Tinnitus is the number-one medical complaint of American military veterans returning from active duty. The resultant ringing, buzzing, pulsing, whistling, or humming noises can be experienced in one or both ears with varying loudness and pitch and may create a struggle between the person and the tinnitus, leading to symptoms of anxiety, fatigue, sleep disturbance, difficulty with concentration, and depression. Tinnitus patients frequently report poor attention and focus, interference with work, and negative impacts on personal relationships. Mindfulness is an approach to the present moment, using a special awareness to shape activity in our nervous system to promote integration and well being in our lives. What it involves is approaching each and every moment that arises with a special kind of 28 hearingreview.com I july 2015

17 awareness. Special in this context means not just an ordinary awareness, but rather full consciousness of immediate experience approached with curiosity, acceptance, openness to whatever arises, and a gentle selfcompassion towards one s self. Approaching the moment with mindfulness is a universal human capacity the ability to use our focal attention to bring conscious awareness of our immediate experience into the spotlight. Building the Awareness Muscle Our minds are designed to be judging machines. We are constantly using memories and learnings from the past to judge our present experience and plan for the foreseeable future. This process can be life-saving when real danger is present. But it can be a false alarm that causes unnecessary suffering when we continually anticipate threats that keep our minds and bodies overreacting and overworking. This is likely occurring in the mind of the person who struggles to habituate to the unpleasant ringing we call tinnitus. The alarming yet often benign and meaningless tinnitus sensation is misunderstood as a potential danger, requiring constant vigilance by unconscious fear-determining centers in our brain. The brain is working overtime to determine if the tinnitus stimulus is life-threatening, requiring a fight-or-flight reaction. This very primitive function in the brain is largely unconscious. It takes patience, discipline, focus, and determination to bring this unconscious activity to our conscious mind. We can then use higher-order executive powers of reasoning and flexibility of response to make reasonable changes to re-perceive what had been automatically mis-perceived all along. It s Not the Ears but What is Between the Ears One question to ask is, What is the difference between the person who experiences bothersome tinnitus versus the person who experiences non-bothersome tinnitus? Most likely it is not what is happening in the ears, but rather what is happening between the ears in other words, what the person is thinking and perceiving. While tinnitus is believed to be initially generated by cochlear damage, it is what happens in the brain next that determines whether tinnitus is considered non-bothersome or bothersome. Non-bothersome tinnitus generally means that, although people hear the sounds associated with tinnitus, they do not develop the frustration, depression, or anxiety associated with bothersome tinnitus. The science behind change and adaptability in the mind. We have learned from neuroscience that the mind is changeable or plastic, meaning the actual neural firing and structure of the brain can change with experience. For the person experiencing bothersome tinnitus, this is certainly good news. Using mindful awareness, we can shine a light on the mind s inaccurate habitual reaction to the tinnitus signal and see it for what it really is: a sensation that does not need to be monitored by the mind, poses no credible threat to survival, and, therefore, can safely fade from our conscious awareness. Quick Tour of the Brain To better understand how tinnitus becomes bothersome, it can be helpful to get a brief overview of brain anatomy. The human brain has three major parts, which developed in succession over millions of years of evolution: Brainstem. The most primitive part is the brainstem, often referred to as the reptilian brain. It is the first part of the brain to develop and is found in all animals. The reptilian brain controls unconscious bodily functions, such as breathing, heartbeat, and sleep-wake cycles. Limbic system. The second part of the brain to develop is the unconscious limbic system, which regulates emotion and memory. One important part of the limbic system, the amygdala, has the specific task of taking in information from internal and external sensations, and determining whether these signals present a potential danger that requires attention and monitoring, or if the stimuli can be safely ignored. (Think of our ancestors on the savannah and their need to determine if a sound meant a tiger was about to pounce on them, or if it was just a branch swaying in the wind?) Cortex. The third part of the brain to evolve is the cortex. In particular, the medial pre-frontal cortex (mpfc) sits directly behind our forehead. It is unique to humans and apes, and allows us to reason, generate conscious thoughts, and regulate emotions. It also enables us to think about thinking (meta-cognition) and become aware of our awareness (meta-awareness), among other higher-order conscious tasks. Using the Medial Pre-Frontal Cortex to Re-assess the Threat of Tinnitus The mpfc plays a key role in correcting misperceptions of tinnitus, an ability called response flexibility. Response flexibility allows us to stop, pause, think, and then choose a thoughtful response without falling back on old knee-jerk habits. This is an important skill for a person with bothersome tinnitus whose brain misperceives the tinnitus signal as something indicating a threat, and who repeatedly reacts without conscious thought to these unfounded fears and frustrations. When the unconscious limbic system and amygdala misjudge the tinnitus as a threat, we can use our mpfc to stop, analyze the facts, and essentially calm the limbic system and the reptilian brain. This gives us the opportunity to rethink and respond to tinnitus in a more accurate and life-affirming way. It is important for people with bothersome tinnitus to remember that their reptilian brain and limbic system are just doing their jobs: constantly scanning the external and internal environment for potential threats. For humans to survive, these automatic systems have been july 2015 I hearingreview.com 29

18 tech TOPIC // Tinnitus hard-wired to get our attention as soon as possible danger is perceived. The problem arises when these unconscious automatic systems misperceive the tinnitus signal as a threat. In fact, tinnitus can be loud and persistent, but does not actually signal that danger is present. Yet, the brain can respond to persistent tinnitus with anxiety, depression, sleep difficulty, and difficulty concentrating. Overcoming False Alarms Training the mpfc to intervene in these constant false alarms and overriding these first impressions with rational thoughts is part of an effective tinnitus treatment. We can use higher-level thinking abilities to unravel the web of stories that loop the mind in a constant state of distraction, worry, and struggle. This all can seem so simple we may have tried to tell ourselves to just relax and take it easy when, for example, we re on an amusement park roller coaster. But blocking out perceived threat is far from easy. In order for the mpfc to communicate with the more primitive unconscious regions of the brain, we need to develop a system of neuronal connections to unlearn our old fears of tinnitus, and to build new communication wiring between our rational mpfc and our automatic reptilian brain and limbic system. Like strengthening and maintaining the strength of a muscle at the gym, this growing of neuronal fibers takes hard work, consistency, and commitment. Strengthening the pre-frontal cortex. Compelling studies support the argument that mindfulness can lead to more adaptive changes in a patient s response to old and new stimuli. Research conducted by Sara Lazar and her colleagues 3 at Harvard suggests that meditation (a well-known mindfulness practice) can lead to cortical growth and thickening in parts of the brain associated with focal attention, fear, and emotional regulation. The study revealed that experienced meditators versus non-meditators were more effective in sending information to unconscious areas of the brain, which can exert more influence on the ability to regulate emotional response, such as a fearful reaction to bothersome tinnitus. This study also determined that the size of the pre-frontal cortex is correlated to the number of years of experience with meditating. These discoveries support the Hebbian theory: Neurons that fire together wire together. When we practice thoughts and actions (ie, regular yoga and meditation), we can strengthen connections within the brain. These connections make for a better opportunity to inform our actions and reactions, as with how we choose to respond to incidents of tinnitus. Such practice contributes to creating new neural networks, so that these pathways can help us correct a misappraisal of the amygdala, allowing us to keep our attention open for other, more important, stimuli. The mind s reappraisal of tinnitus. It is believed that the amygdala in some individuals with tinnitus mis-appraises the level of threat that the tinnitus sound represents, and this may be the reason why some people experience bothersome tinnitus while others do not. Most cases of tinnitus begin with some degree of hearing loss, but not all people with hearing loss have tinnitus. It stands to reason that the difference between those who experience bothersome tinnitus and those who don t is not hearing loss; rather, it is the appraisal of threat that the amygdala assigns to the tinnitus sensation. It may be that the people who experience bothersome tinnitus remain on chronic alert to the sensation, while those who interpret the tinnitus sensation for what it is a meaningless, benign perception of a sensation are able (automatically/sub-consciously) to allow the sensation to drop into the recesses of awareness. We know through science and experience that tinnitus in and of itself is not a cause for alarm and can safely be sent to the recesses. How, then, might we reassure ourselves of this, and assist the amygdala in choosing the more benign response? MBTSR and brain training. A central goal of mindfulness-based programs is to help participants train the brain to convince the fast-acting and mis-appraising amygdala that keeping tinnitus in our awareness is a waste of our energy and resources. Like the sound of a white noise machine or fan, tinnitus also can safely recede into the recesses of our mind. Convincing the amygdala of this fact is the job of the higher developed areas of the brain. As mentioned earlier, the pre-frontal cortex conducts our executive functioning tasks, including judgment, reasoning, emotional regulation, bringing awareness to certain things, and fear modulation, to name a few. This conscious part of the brain can be enlisted to exert more control over bringing awareness to certain processes, such as fear modulation and response flexibility (ie, think before you act). The goal here is to chill out the amygdala, so that we can recruit and utilize a more accurate appraisal of the tinnitus sensation. The pre-frontal cortex is slightly slower in processing than the amygdala. This partly explains why our brains tend to place sounds in the better-safe-than-sorry danger category. Research in brain anatomy and physiology shows that, when directed, the pre-frontal cortex sends fibers to the overactive amygdala. These fibers are the down-regulating neuropeptides, such as GABA, that serve to calm down this area so that we can use reasoning to put tinnitus in the benign category, where it belongs. Mindfulness: The Personal Trainer of the Pre-Frontal Cortex A Mindfulness-based approach, and the 8-week MBTSR course specifically, builds these new mental muscles. Because many people have lived with bothersome tinnitus for years or decades, there are a lot of familiar patterns that they feel are impossible to overcome. However, with diligent practice, MBTSR teaches step-by-step skills needed to help the thinking brain more accurately determine real threats, and to calm knee-jerk reactions to bothersome tinnitus. The activated reptilian brain and limbic system are like anxious children; you don t want them in the driver s seat, but you also don t want to stuff them in the trunk. MBTSR can help place the mpfc in the driver s seat, while acknowledging the importance of the brainstem and limbic system. A mindfulness approach to tinnitus helps extinguish the automatic fear reaction and replaces it with a letting go of attention and perception of tinnitus. The MBTSR program focuses on helping people uncover their own internal resources toward a reinterpretation of tinnitus. With practice, people with tinnitus are capable of More Firing, More Wiring : strengthening connections in the pre-frontal cortex for a greater, more measured, balance in daily life. This is an important step towards unraveling the Gordian Knot of tinnitus. references can be found at www. hearingreview.com or by clicking in the digital edition of this article at: correspondence can be addressed to Dr Gans at: JG@ more INFORMATION about the 8-week MBTSR course can be found at: 30 hearingreview.com I july 2015

19 References 1. Gans JJ, O Sullivan P, Bircheff V. Mindfulness based tinnitus stress reduction pilot study. Mindfulness. 2013;5(3)[June]: Available at: springer.com/article/ %2fs #page-1 2. Gans JJ, Cole MA, Greenberg B. Sustained benefit of mindfulness based tinnitus stress reduction (MBTSR) in adults with chronic tinnitus: A pilot study. Mindfulness. 2015; In Press. Available at: springer.com/article/ %2fs x#page-1 3. Lazar SW, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17)[Nov 28]: Available at: july 2015 I hearingreview.com 31

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