What Causes Tinnitus?

Explore how changes in brain processing lead to tinnitus, and how cognitive-behavioral approaches can help manage distress associated with this condition.

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Professional version

Offers theory, guidance, and prompts for mental health professionals. Downloads are in Fillable PDF format where appropriate.

Client version

Includes client-friendly guidance. Downloads are in Fillable PDF format where appropriate.

Editable version (PPT)

An editable Microsoft PowerPoint version of the resource.

Overview

Tinnitus is the perception of sound without an external source, arising when the brain’s normal filtering mechanisms fail to suppress internal auditory signals. This loss of filtering means that sounds which would typically go unnoticed enter conscious awareness. While the perception of tinnitus itself is the result of this altered processing, the associated distress stems from how the sound is interpreted. When tinnitus is appraised as threatening, uncontrollable, or harmful, it draws focused attention, triggers emotional responses such as anxiety or frustration, and becomes increasingly intrusive. This information handout describes these processes using client-friendly terminology.

Why Use This Resource?

This resource is designed to support mental health professionals working with clients experiencing tinnitus or hyperacusis.

  • Explains the psychological and cognitive-behavioral understanding of tinnitus.
  • Helps therapists understand how thoughts and beliefs influence the perception and impact of tinnitus.
  • Serves as a starting point for exploring clients’ beliefs, interpretations, and emotional responses to tinnitus.

Key Benefits

Insight

Offers a clear model explaining how tinnitus is related to brain processing and appraisal changes.

Awareness

Helps clients and therapists alike understand the role of cognitive attributions in the perpetuation of tinnitus.

Practical

Can be directly used in therapy sessions or as an educational handout for clients.

Who is this for?

Tinnitus

Clients who are distressed by the perception of internal sound, struggling with attention, emotional reactions, or unhelpful beliefs about the noise they hear.

Hyperacusis

Clients who experience heightened sensitivity to everyday sounds, often accompanied by fear, avoidance, or distress related to certain auditory environments.

Integrating it into your practice

01

Describe

Use the handout to clearly describe the psychological approach to tinnitus.

02

Explore

Encourage clients to identify and explore negative apparaisals tied to tinnitus.

03

Discuss

Facilitate discussions about the emotional reactions linked to tinnitus perception.

04

Reflect

Foster client reflection on how their thoughts may impact the persistence of tinnitus.

Theoretical Background & Therapist Guidance

The cognitive-behavioral model of tinnitus builds on earlier work such as Jastreboff’s neurophysiological model (1990), which proposed that tinnitus becomes distressing not because of the sound itself, but due to how it is interpreted and appraised. While tinnitus often begins with changes in the auditory system — such as hearing loss — distress arises when the brain fails to filter out the sound and instead assigns it threatening meaning.

In individuals who do not find tinnitus distressing, the brain habituates to the sound, treating it as neutral background noise. In contrast, when tinnitus is appraised as dangerous, uncontrollable, or a sign of ongoing damage, it becomes emotionally salient. This increases autonomic arousal, draws attention to the sound, and reinforces the belief that the tinnitus is harmful or unbearable. Over time, a self-perpetuating feedback loop develops: attention and distress heighten perception, and the perception confirms threat appraisals (McKenna et al., 2014).

Cognitive-behavioral therapy (CBT) aims to break this cycle by helping clients reappraise the meaning of tinnitus, reduce avoidance, and manage emotional responses. Acceptance and Commitment Therapy (ACT) has also been applied to tinnitus with promising results. ACT shifts the focus from symptom reduction to building psychological flexibility — helping clients relate differently to tinnitus through acceptance, mindfulness, and values-guided action. Rather than trying to control or eliminate the sound, ACT encourages individuals to allow tinnitus to be present without struggle, and to engage in meaningful activities despite it (Westin et al., 2011; Beukes et al., 2018).

What's inside

  • Illustrated information handout detailing key processes in tinnitus perception.
  • Sections explaining the interaction between thoughts, emotions, and tinnitus perception.
  • Suggestions for how this information can be used in various clinical settings.
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FAQs

Tinnitus is the perception of noise or ringing in the ears without an external sound source.
Tinnitus is linked to changes in the brain's filtering mechanism, failing to suppress internal noises, leading to heightened awareness and perception.
CBT helps by altering negative thought patterns about tinnitus and reducing the distress associated with its perception.
While it's specifically for tinnitus, the insights into cognitive processing and emotional reactions can be useful for addressing hyperacusis.

How This Resource Improves Clinical Outcomes

By using cognitive-behavioral models to better understand tinnitus, clients can develop:

  • Enhanced insight into how their thoughts and emotions impact tinnitus perception.
  • A reduction in distress and anxiety related to tinnitus.
  • Greater ability to manage tinnitus through cognitive restructuring and emotional regulation techniques.

Therapists gain:

  • An illustrated educational tool for explaining tinnitus within a cognitive-behavioral framework.
  • A resource for working with clients experiencing psychological distress due to tinnitus.

References And Further Reading

  • Jastreboff, P. J. (1990). Phantom auditory perception (tinnitus): Mechanisms of generation and perception. Neuroscience Research, 8(4), 221–254. https://doi.org/10.1016/0168-0102(90)90031-9
  • McKenna, L., Handscombe, L., Hoare, D. J., & Hall, D. A. (2014). A scientific cognitive-behavioural model of tinnitus: Novel conceptualizations of tinnitus distress. Frontiers in Neurology, 5, 1–15. https://doi.org/10.3389/fneur.2014.00196
  • Westin, V. Z., Schulin, M., Hesser, H., Karlsson, M., Noe, R., Olofsson, U., & Andersson, G. (2011). Acceptance and commitment therapy (ACT) as a treatment for chronic tinnitus: A randomized controlled trial. Behavior Research and Therapy, 49(11), 737–747. https://doi.org/10.1016/j.brat.2011.08.001
  • Beukes, E. W., Andersson, G., Allen, P. M., Manchaiah, V., & Baguley, D. M. (2018). Effectiveness of guided internet-based cognitive behavioural therapy vs face-to-face clinical care for treatment of tinnitus: A randomised clinical trial. The Lancet, 391(10111), 2483–2491. https://doi.org/10.1016/S0140-6736(18)31390-0