One of the most common worries that people have when they are diagnosed with tinnitus is whether it’s a psychological condition: ‘Am I going mad, doctor?’ The simple answer to this question is ‘no’, and to my knowledge this is agreed upon by every clinician and researcher specialising in tinnitus.

Although we do not fully understand what exactly causes tinnitus, all the current theories involve specific mechanisms in the brain, and psychological factors are not involved as a fundamental cause of tinnitus. We do know that the cause of most cases of tinnitus is a degree of hearing loss, which can be anywhere from severe to too mild to detect with standard hearing tests.

Many experts liken tinnitus to pain caused by nerve damage. However, the inner ear that is damaged in tinnitus rather than sensory nerves, and it is a sound that is perceived rather than a pain (though tinnitus can include pain in some cases).

What causes people to think tinnitus is a psychological condition?

There are a few things about tinnitus, which might lead to the impression of it being in part a psychological condition if taken out of context:

1.    The most effective evidence-based treatment for tinnitus, in terms of improving the misery it causes and restoring quality of life, is psychological treatment, such as cognitive behavioural therapy (CBT).

The reason for this is that tinnitus research has not yet produced treatments that are effective in quieting or eliminating the tinnitus sound itself for most people who experience it. What psychologically based treatments aim to do is not to change the tinnitus sound itself, but to help people to notice the tinnitus sound less often and, when they do notice it, to help remove negative reactions to the sound that lead to suffering. Where tinnitus is causing significant distress, these treatments can make a huge difference.

Returning to the comparison to pain, there are various medications and other methods that are enough to provide effective relief for some people.  However, chronic (i.e. long-term) pain is a major problem for many people, and psychological interventions like those used for tinnitus have a very important role to play for many of these individuals. As with tinnitus, the role of psychological therapy in pain does not imply that the cause of the pain is psychological, but indicates that other treatment options available are insufficient to satisfactorily suppress or eliminate the pain signal.

2.     There is no medical test for diagnosing tinnitus, and therefore it could be argued that there is ‘no proof that it is not psychological’. The first thing to say in response to this is that many medical conditions throughout history (and even currently) do not show up on available tests, and that this just reflects the limitations of medical tests. In these cases, doctors can often make a diagnosis based on recognising a familiar set of symptoms that classically go together, particularly when these are very consistent in how they are described and reported by multiple different people. Although there is variation in tinnitus symptoms, in general there is remarkable consistency across individuals with tinnitus in how they describe and report the sound itself, and how it behaves in response to various situations in life and noise environments.

The other thing to say is that several research groups have shown that there are changes that can be detected in the brain in people with tinnitus compared to people without. Although these have not been turned into diagnostic tests for use in medical care (mainly because such a test is unnecessary, as people can simply say whether they hear tinnitus), they do suggest that tinnitus does have a specific neurological basis that can be detected with appropriate tests.

In short:

  • Tinnitus is understood to be a neurological condition, usually caused by hearing damage.

  • The brain mechanisms behind tinnitus can potentially be detected using cutting edge techniques, at least in groups of people with tinnitus rather than individuals, but they are still not fully understood.

  • Although the basis of tinnitus is not thought to be psychological, where it causes significant distress or reduction in quality of life, psychologically based treatments such as CBT can result in major improvements in these consequences.

Author: Dr William Sedley, Academic Clinical Lecturer in Neurology, Newcastle University

Published: 27 September 2019

Image: Gus Moretta via Unsplash