The What Keeps Tinnitus Going? handout presents key factors that maintain tinnitus.
Offers theory, guidance, and prompts for mental health professionals. Downloads are in Fillable PDF format where appropriate.
Includes client-friendly guidance. Downloads are in Fillable PDF format where appropriate.
An editable Microsoft PowerPoint version of the resource.
What Keeps Tinnitus Going? is a tinnitus formulation diagram which combines information about neurological-level change (the brain’s ‘filter’) and psychological-level change (thoughts, feelings, and behavior) to come to an understanding of why tinnitus often fails to improve.
Understanding what exaccerbates tinnitus going is crucial for effective intervention. By identifying these factors, therapists can develop idiosyncratic models of clients' experiences and focus their interventions.
Clients who are struggling with persistent and intrusive ringing or buzzing in the ears may develop heightened emotional reactivity, anxiety, and difficulty regulating attention.
Explain to the client that certain difficulties persist due to cycles that maintain them.
Use the handout to discuss what might be keeping the client's difficulties going.
Pinpoint and personalize maintaining factors that are relevant to the client.
Explore how these maintaining cycles can be interrupted.
The What Keeps Tinnitus Going? handout is based on a cognitive-behavioral formulation that incorporates both neurological and psychological processes to explain the persistence of tinnitus-related distress. This integrated model helps clinicians and clients collaboratively understand how tinnitus becomes distressing and why it often fails to habituate over time.
Tinnitus typically begins with an initial perception of sound in the absence of an external stimulus, often triggered by hearing loss or auditory system changes. While many individuals perceive tinnitus at some point, only a subset find it distressing or disruptive. The brain’s auditory system normally filters out unimportant sounds — but when tinnitus is interpreted as significant or threatening, this filtering fails. This process of salience assignment — the brain treating tinnitus as a stimulus that requires attention—is a core feature of the neurocognitive model (Rauschecker et al., 2010; De Ridder et al., 2011).
The persistence of tinnitus distress is shaped by how individuals interpret the sound. Negative appraisals—such as “This will never go away,” “It means something is wrong with me,” or “I can’t cope with this” — lead to heightened emotional responses including anxiety, anger, and hopelessness (McKenna et al., 2014). These emotional states are associated with increased physiological arousal, which in turn enhances the perceptual salience of tinnitus, making it more intrusive and harder to ignore (Andersson & McKenna, 2006).
Tinnitus sufferers frequently display hypervigilance toward the tinnitus signal, checking or monitoring for changes. Research suggests that attentional bias toward tinnitus plays a significant role in distress maintenance (Cima et al., 2011). Attempts to suppress awareness of the sound often backfire, increasing the perceived intensity and intrusiveness of tinnitus (Cima et al., 2012).
Coping behaviors such as avoiding silence, sleeping with excessive masking noise, or withdrawing from activities due to fear of aggravating tinnitus can limit exposure to disconfirming evidence and reduce opportunities for habituation. These safety behaviors inadvertently maintain distress by reinforcing beliefs that tinnitus is dangerous or uncontrollable (Hesser et al., 2011).
Together, these interacting components—altered filtering of sound, threatening appraisals, emotional distress, hypervigilance, and unhelpful coping behaviours—create a self-perpetuating cycle. The What Keeps Tinnitus Going? diagram makes these processes explicit, supporting collaborative formulation and intervention. Therapists can use the model to normalise clients’ reactions, reduce fear and stigma, and target specific maintenance mechanisms through CBT strategies such as cognitive restructuring, exposure, relaxation training, and mindfulness.
