British Tinnitus Association

Tania Salvo, Jenna Love & Laurence McKenna, Royal National Throat Nose & Ear Hospital
 
What is stress?
Stress is experienced by nearly everyone at some point in their lives. Stress occurs when the demands on a person do not match that person’s biological, psychological or social resources. This can happen when the demands are too high, such as when a person has too much to do. It can also occur however when the demands are too low, when for example a person is under-employed. Contrary to popular belief, stress is not all bad for our health. A certain amount of stress, or arousal, can help us to focus on the task in hand and the release of stress-hormones can help our bodies to perform certain activities (such as tackling a dangerous situation or running away to a safe place). Therefore in the short term, stress may be necessary for us to function well. In the longer-term, however, prolonged stress can be very uncomfortable for our bodies and our minds. 
 
How to recognise when we are stressed
The experience of stress varies widely in different people. Here are some possible signs of stress to look out for, in your body, thinking and behaviour. You may already be aware of some of these indicators of stress. It may be that you have not recognised others as stress related.    
 
Signs of stress in your body

• Feeling tense
• Quickened heart beat
• Breathlessness or a change in your breathing, e.g. lots of yawning or sighing
• Churning stomach, ‘butterflies’ or nausea
• Sweating
• Needing the toilet (empty bowels/bladder)
• Poor concentration
• Disrupted sleep

Signs of stress in your thoughts
 
A sense of being overwhelmed or that there is too much to deal with, for example:

• “I can’t cope with this”
• “I’m never going to get everything done in time”

It is also likely that your thoughts will become very focused on the thing that is stressing you. It may therefore be difficult to concentrate on other things. One result of this is that the problem will seem to grow in importance. This process is known as selective attention. 
 
Signs of stress in your behaviour

• Stopping doing things you enjoy, such as seeing friends, hobbies, reading
• Doing more of things to try and manage the stress such as drinking more alcohol, smoking more, exercising less.

Over time, these things may maintain the feelings of stress and can also become problems of their own. Feelings of stress can also occur with, or lead to, other difficult feelings such as feeling low in mood.
 
Causes of stress – Cognitive Behavioural Framework
Many factors can contribute to stress, including current situations and past experiences. A cognitive behavioural (CBT) framework is a way of understanding
how the factors which contribute to stress are linked. This therefore helps us to understand why people experience stress, and think about how to help them reduce this.
The CBT model suggests that the way we feel – whether that is stressed, worried, depressed, happy or any other emotion - is strongly influenced by what we think and what we do. Therefore it is not just what happens to us that results in stress or other emotions, but the way we think about these events.
For example, imagine you are walking down a road and see someone you know on the opposite side of the road; you wave to them but they walk right past. You might think ‘how rude’ and feel angry. Alternatively, you might think ‘what have I done to upset them?’ and feel hurt. You might think any number of things. The CBT model proposes that the way you feel is largely determined by the thoughts you have about the situation – or in other words, your interpretation – rather than the situation by itself.
To take a different example, imagine that you are late for a meeting. You might be saying to yourself ‘how awful to turn up late, they are going to think I’m unreliable’ or ‘how could I have been so stupid not to leave earlier’. Thinking in this way certainly adds to the level of stress you are feeling. Again, stress is not only due to the situation but our interpretation. 
 

The relationship between Stress and Tinnitus
The way people respond to tinnitus varies greatly. For some people, it is considered the biggest stress in their life whilst others will respond to it in a neutral, calm way. You might suppose that this difference is due to different people having different tinnitus. This would make sense, but the research evidence on tinnitus does not support this idea. Instead the evidence suggests that the reason one person is stressed and another not is because they have different ideas about tinnitus. People who are stressed by their tinnitus tend to think about their tinnitus in ways that reflect despair, persecution, hopelessness, loss of enjoyment, a desire for peace and quiet and a belief that others do not understand. They may resent the persistence of tinnitus, wish to escape it and worry about their health and sanity. When thought about in these terms tinnitus can be associated with a great deal of stress, and we will consider the impact of such thoughts shortly.
Additionally, various emotional and physical factors have been linked to the onset of tinnitus, including stress. Although it is not always clear whether stress causes the onset of tinnitus, or perhaps is a contributing factor, it is common for tinnitus to start at times of high stress or after a period of stress. It is also common for existing tinnitus to become worse during periods of high stress. For some people, tinnitus acts as their ‘barometer’ of stress, often worsening when there are difficult things going on in their life. Of course, the worsening of tinnitus when we are already feeling stressed can add another burden, and lead to a ‘vicious circle’ as each influences each other.

 

 
Attention and habituation
The relationship between tinnitus and stress can be understood by considering the role of attention. Every minute of every day we receive hundreds of pieces of information from the environment. It is not possible for us to pay attention to all this information at one time. Fortunately we have a system that allows us to select what we attend to at any given moment. The rest of the information is filtered out. The information that is filtered out is usually repetitive or unimportant. So for example, if we consider the ticking of a clock, we will very often not react to it and may forget that it is there unless we consciously draw our attention to it. In other words, we will habituate to it.  
However, if information is seen as threatening and it leads to stress arousal then you will have difficulty habituating to it. In fact, if information is seen as emotionally important and your body is on alert then the opposite of habituation may happen, you may become more sensitive to the perceived threat. All this is relevant to tinnitus. If you see your tinnitus as a threat to your wellbeing your attention will focus on it. In such circumstances you monitor it, as you would any perceived threat. The process involves you not only focusing on tinnitus but also paying less attention to other things in the environment. Focusing attention on tinnitus in this way may lead to the tinnitus seeming to be much louder and much more intrusive, much like turning on the spotlight on tinnitus.
These changes in attention can therefore explain why tinnitus may start or become worse during periods of stress. It also might explain why the majority of people with tinnitus are able to experience the noises without being overly distressed by them. 
 
Managing the stress of tinnitus
Making changes in one or more of the areas in the cognitive-behavioural model can help you to reduce unpleasant feelings, such as stress, whether that is associated with tinnitus or with other troubles in your life. 
 
Thoughts
Your thoughts are extremely important in influencing how you feel. Therefore it can be useful to pay more attention to your thoughts and work out whether they are helpful or not. Work through these steps to try and uncover and tackle unhelpful thoughts about your tinnitus:
1)     Become aware of particular situations/times when you are especially distressed by your tinnitus.
2)     Ask yourself “what went through my mind at that time?” and then write down the thought.
3)     Use the following questions to evaluate these thoughts:

• What tells you that the thought is true - what evidence supports the idea?
• Is there anything that tells you it is not true - what evidence do you have against it?
• What is the worst thing that could happen?
• If a friend asked you for help about the same problem what would you say to them?
• What would a friend say to me?

 
By doing this, you may be able to develop more helpful things to say to yourself about your tinnitus – for example reminding yourself that it is not dangerous and it is possible to still enjoy life with tinnitus. Changing the messages you tell yourself about tinnitus can help to reduce the impact on your life. 
 
Physical reactions
Relaxation can be used as a way of dealing with the physical reactions associated with stress. Relaxation can take different forms for different people, but you may like to set aside some time to relax every day. Try not to expect this to help your tinnitus directly or straight away; most people find relaxation helpful but it requires time and practice. For more information, see the BTA leaflet on ‘Relaxation’. 
 
Behaviour
Some people find changes in their behaviour can help them to better manage their tinnitus, for example by focusing their attention more on interesting activities and less on the tinnitus. There are also a number of ideas that may reduce your general stress levels, which may also positively impact your tinnitus:

• Exercise
• Making time for yourself
• Spending time doing enjoyable activities and socialising
• Problem solving or changing things in your life that cause you stress, if this is possible
• Talking to supportive people – either friends and family or a counsellor or psychologist.

December 2009 © British Tinnitus Association
This information is not a substitute for medical advice. You should always see your GP / medical professional