Dr. Nagler's Tinnitus Site

Dr. Nagler’s Tinnitus Site

Tinnitus Retraining Therapy (TRT)

Tinnitus Retraining Therapy (TRT) is one of many approaches currently available for the treatment of tinnitus. The overall goal in TRT is for tinnitus to cease being an issue in the life of the individual. In this regard, it cannot truly be viewed as a technique for coping with or "learning to live with" tinnitus, since one neither needs to cope with nor learn to live with an entity that is no longer an issue in one's life. TRT was developed in the late 1980's by Pawel J. Jastreboff, PhD, ScD in clinical consultationand association with Jonathan W. P. Hazell, FRCS. It is based upon the "Neurophysiological Model of Tinnitus," a model described, studied, and published in detail.

Tinnitus Retraining Therapy depends upon the natural ability of the brain to "habituate" a signal, to filter it out on a subconscious level so that it does not reach conscious perception. Importantly, habituation is a passive event, in contradistinction to "ignoring" something, which is an active event. Thus habituation requires no effort. People frequently habituate many auditory signals - we initially hear sounds from, for instance, air conditioners, computer fans, refrigerators, and gentle rain only to have their signals rapidly disappear from conscious awareness unless we purposely seek them out. (A few seconds after a refrigerator "kicks on," we no longer "hear" it.) The two elements that air conditioners, computer fans, refrigerators, and gentle rain have in common are that the signals they emit have no importance, and that the signals are not perceived as "loud."

The signal of tinnitus has great meaning to the tinnitus sufferer, and it is, indeed, perceived as loud. The entire thrust of TRT is (1) to remove the meaning from the signal and (2) to convert it from a loud sound to a soft sound - so that it can be naturally and effortlessly habituated. More specifically TRT is a method of retraining the brain to process the loud meaningful tinnitus signal ... as a signal that is not loud and not meaningful - so that the tinnitus can be naturally and effortlessly habituated. Thus, Tinnitus Retraining Therapy is a protocol for the facilitation of habituation.

The neurophysiological model of tinnitus holds that importance and meaning are given to the tinnitus signal in a subconscious (subcortical) area of the brain near the medial temporal lobe called the "limbic system." The limbic system is comprised of the hippocampus, amygdala, mamillary bodies, and associated structures. It is a major seat of emotion, and it attaches importance to the tinnitus signal for one (or a combination) of three reasons:

fear of an unknown danger (why did this happen; will it get worse?)
"negative counseling" (you'll just have to learn to live with it; I knew someone who had it so bad she committed suicide)
continuous repetition of a meaningless signal (the "Chinese" water torture, in which incessant drops of water evenly spaced apart were supposedly allowed to fall upon the head of a prisoner thereby driving him to such distraction and eventual torment that he would divulge any and all secrets)

In TRT, a process called "directive counseling" is used to assist in resolution of the intimate associations among the tinnitus signal, the limbic system, and the autonomic nervous system, a part of the brain that functions in a protective role. Directive counseling has little in common with the gradually increasing self-realization of traditional psychological counseling; rather, directive counseling takes the form of a series of intensive, interactive, individualized educational sessions - including an initial session and two or three follow-up sessions over a twelve to eighteen month period. During directive counseling the tinnitus sufferer participates in an in-depth discussion in which the source and meaning of his or her tinnitus is detailed through demonstrations of anatomy (structure), physiology (function), and real examples in "story format" to make the tinnitus phenomenon understandable and demystified. Essential in directive counseling is a thorough explanation of the rationale and importance of healthy neutral non-masking sound (see second paragraph below) in the ultimate resolution of the problem. The directive counseling structure remains basically the same in each of the sessions; however, the nature and detail of the explanations and the analogies used changes as the sufferer's view of his or her tinnitus gradually matures during the process.

Prior to commencement of directive counseling, the tinnitus sufferer must undergo a thorough ENT and audiological evaluation as well as preferably a thorough tinnitus-oriented medical evaluation to rule out any of the rare causes of tinnitus which might require medical/surgical attention or which might result in a true cure. Once factors of medical, ENT, and audiological concern have been considered, it is not inappropriate to address the symptom of tinnitus irrespective of etiology. Additionally, it should readily be apparent that until such issues are resolved, any attempt to remove importance from the tinnitus signal will be met with failure. It should also be apparent that "directive counseling" is largely an art - success is highly dependent upon the ability of the clinician to convey the important principles to the tinnitus sufferer in an individualized relevant fashion, upon the ability of the sufferer to absorb and apply the information thus presented, and upon the rapport established and maintained between clinician and sufferer. In this sense, the process may be considered analogous to the relationship between a teacher and a student, between a therapist and a patient, and between a sculptor and a piece of marble. It has been my experience that both the clinician and the patient are changed by this therapeutic event - both derive benefit, but not without considerable mutual effort.

Thus, directive counseling is used to gradually remove the meaning from the tinnitus signal, but if the signal is still perceived as "loud," it is incredibly difficult to habituate. (Note how much easier it would be for the average individual to habituate the meaningless sound of a refrigerator motor in the kitchen compared to the meaningless sound of an "express" subway train as it screams by that same individual standing on the platform at a "local" stop.) The key to converting the loud sound encountered as the tinnitus signal is perceived into a much softer sound, a sound that is more readily habituated, lies in the neurophysiological principle that the brain interprets sensory signals in terms of contrast rather than absolute magnitude. Dr. Jastreboff uses the example of a candle on a birthday cake to elegantly illustrate this point. Picture a dark room containing a birthday cake with a single lighted candle. In this dark environment, the pupils in the celebrants' eyes are, of course, dilated - an event beyond conscious control. The "gain" on the celebrants' visual systems is automatically increased as all possible visual stimuli are taken in - a state of subconsciously heightened awareness. The flame on the birthday candle is interpreted as "bright." Now, turn the lights on in the room. The celebrants' pupils constrict (no subconscious effort is made to seek out more visual stimuli - the "gain" is turned down), and the candle does not appear as bright. So one candle, giving off an identical magnitude of energy in two different environments - a dark room and a room with lights on - will be interpreted by the visual centers of the conscious brain as "bright" in one instance and "not particularly bright" in the other. The same thinking may be applied to 1/4 teaspoon of steak sauce placed directly on the tongue compared to the same volume of steak sauce eaten along with a piece of steak. In one instance, it is exceedingly "hot;" in the other, it is nothing more than a complementary flavor. With respect to the sense of hearing, compare the impression that a solo violinist makes upon conscious auditory awareness to that of the same violinist, playing with identical intensity, when the orchestra joins in at the conclusion of the cadenza. Our conscious brain interprets sight, taste, touch, smell, and - most importantly for our purposes - sound in terms of sensory contrast rather than absolute magnitude.

In TRT, non-masking sound is used both to decrease the contrast between the tinnitus signal and the environment and to allow the auditory system to "turn down the gain" so that auditory signals are not unnecessarily magnified. Thus the principle of sensory contrast is used physiologically to decrease the "loudness" of the tinnitus - since we interpret auditory stimuli by contrast and not by absolute magnitude. The non-masking sound may be supplied in one of three ways:

Very basically, the tinnitus sufferer is instructed to place some source for neutral sound everywhere he or she goes. The source can be a CD player, a radio, a tabletop "sound machine" - it is irrelevant. The type of sound - white noise, music, nature sounds - is also largely irrelevant; however, the intensity is not irrelevant. The sound may not mask (cover) the tinnitus signal, for one cannot habituate a signal one does not hear. Simply stated, environmental silence is to be avoided.
In the case of the tinnitus sufferer with a significant hearing impairment, amplification (hearing aids) is provided to augment the (above mentioned) environmental sounds. Effort must still be made to avoid environmental silence, since augmented silence is still silence.
Most frequently, the tinnitus sufferer finds that if he or she wears white noise generators binaurally (both ears), purposely avoiding environmental silence is no longer a factor since it is done automatically by the wearable white noise generators. These wearable devices are strictly a convenience, but often a welcome one, and they are only used during the twelve to eighteen months generally required to effect auditory habituation of tinnitus. They are set at an intensity below that which would be necessary to achieve masking - again, because one cannot habituate a signal one does not hear. "Open molds" are fashioned, so that the devices do not interfere at all with hearing other sounds - music, the spoken word, etc. They are used in both ears, even in the case of one-sided tinnitus so that the entire auditory system may be exposed to neutral non-masking sound. Very importantly, in the case of tinnitus arising in a deaf ear, a single white noise generator may be used in TRT effectively in the non-deaf ear to achieve a decrease in auditory gain and a decrease in sensory contrast since we actually hear with our brains and not with our ears. Crucial in this concept is the presence of numerous "cross-over fibers" in the auditory pathway; sound waves entering any one ear or tinnitus signals generated in any one cochlea (or further up the auditory pathway) are appreciated on both sides of the brain. One further advantage of using wearable white noise generators to decrease sensory contrast lies in the fact that the unobtrusive meaningless sound produced by such devices is itself very easily, effortlessly, and naturally habituated.

Tinnitus Retraining Therapy, therefore, involves two essential elements: 1) the use of non-masking sound (wearable, amplified, or environmental) to decrease sensory contrast, and 2) directive counseling presented within a prescribed framework, applying the principles of the neurophysiological model of tinnitus on a highly individualized basis. The importance of this second element, the directive counseling, cannot be over-emphasized.

Finally, what is the desired result of TRT? Since TRT is clearly not a cure, what is considered to be a successful result? Ideally, the tinnitus sufferer will initially habituate the response to tinnitus (tinnitus will not be annoying) and ultimately habituate the perception of tinnitus (tinnitus will not be heard unless it is sought). The process of habituation of tinnitus, a meaningful and perceptively loud phenomenon, requires an average of twelve to eighteen months of treatment. In practical terms, an ideal result would be obtained if the (former) tinnitus sufferer were unaware of the tinnitus more than 90% of waking hours, and if when aware of the tinnitus, it would not be bothersome. At the conclusion of TRT, there is, of course, no need to continue to use any wearable white noise generators, if such devices have previously been chosen as the method for decreasing sensory contrast.

In summary, Tinnitus Retraining Therapy represents a valid effective addition to the armamentarium of the clinician who treats tinnitus patients. The approach is based on science; the execution of the directive counseling aspect of the therapy is largely dependent upon the skills of the clinician and upon the time and effort devoted to this crucial element in the treatment. The model, the method, and the results have been published in peer-reviewed journals.

TRT is not a cure for tinnitus. It is a treatment approach designed with the goal of tinnitus ceasing to be an issue in the patient's life. It is designed with the goal of making tinnitus into a pair of pants. Ninety percent of the time, people are unaware of their pants. The 10% of the time they are aware, they do not "cope" with their pants, they do not "deal" with their pants, they do not "learn to live" with their pants, and they most certainly do not spend any time worrying whether the following day will be a "good pants day" or a "bad pants day." They simply wear their pants; and when the goal of TRT has been met, tinnitus should be just like that!

Stephen M. Nagler, MD, FACS

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