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Lucie14

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 #1 
Hello Dr. Nagler,

I posted to your forum several times last spring and summer, and I also spoke with you for a very helpful 1x1. Nine months into this tinnitus journey, I seem to be making progress. Overall I've had many days on which the tinnitus, while definitely there, has not bothered me very much.

I'm at a point where I do have some questions about the habituation process -- and hoping you can help.

1. While I have many good days, I still have days here and there on which the tinnitus is challenging. Is this typical?
2. I try not to "figure out" the tinnitus, but some days are markedly louder than others, for no apparent reason -- other than maybe shifts in the weather! Is this typical?
3. Does full habituation mean one doesn't hear the tinnitus at all, unless one listens for it? Does it mean one hears the tinnitus, but it does not cause stress or bother? Are both considered habituation, just different levels?
4. Even when habituated, are you still supposed to avoid silent environments? I wasn't sure if that goal to avoid silence falls away at some point.
5. I feel impatient that a deeper level of habituation is not happening more quickly for me. I do use CBT techniques and they've been beneficial. I also know a person with tinnitus who said it took him two years to reach that "don't hear it unless you listen for it" level. Are there typical time frames / guidelines for habituation? Or is it highly individual?

Thanks as always for all you do!
Lucie14
Dr. Nagler

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 #2 
Thank you for your post, Lucie14.

Please check back tomorrow for my response to your excellent questions.

Stephen M. Nagler, M.D.

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The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Dr. Nagler

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 #3 
Quote:
Originally Posted by Lucie14
1. While I have many good days, I still have days here and there on which the tinnitus is challenging. Is this typical?

Yes, the typical as one habituates is like a sine wave with overall positive slope. In other words, there are good days and not-so-good days, but as you look month to month there is a trend towards improvement.

Quote:
2. I try not to "figure out" the tinnitus, but some days are markedly louder than others, for no apparent reason -- other than maybe shifts in the weather! Is this typical?

I am sure you know my favorite saying: The first step to overcoming your tinnitus is when you have finally figured out that you can't figure it out at all. But that said, it's only natural to try to figure it out from time to time - so please don't reproach yourself. And, yes, what you describe is fairly typical (and it has nothing to do with the weather!)

Quote:
3. Does full habituation mean one doesn't hear the tinnitus at all, unless one listens for it? Does it mean one hears the tinnitus, but it does not cause stress or bother? Are both considered habituation, just different levels?


Strictly speaking there are two definitions for habituation:
  • The passive extinction of a conditioned response to a neutral stimulus
  • The natural attenuation of a non-reinforced response to a repeated stimulus over time
I am not offering those definitions because they are simple, clear, and easy to understand. They aren't! Rather I am offering them to point out that regardless of which definition one uses, habituation is all about response (i.e., reaction). Nowhere in either definition does the word perception appear at all.

What this means in terms of tinnitus is that habituation does not directly involve whether or not one is aware of one's tinnitus under this, that, or the other circumstance. The idea that habituation means a loss of tinnitus awareness grew out of Dr. Pawel Jastreboff's Neurophysiological Model of Tinnitus, where he coined to term "Habituation of Perception" (Hp) to fit in with his model. So where does perception come in? Well, the brain is an extremely busy organ; even when you are doing nothing at all, your brain is very busy. And the only way the brain can get everything done that it needs to get done (even when you are doing nothing!) is by prioritizing. Simply stated, the brain pretty much doesn't bother attending to things it does not react to! Moreover, as a corollary the brain attends less to things it reacts less to.

Now, back to your original question. Habituation is a process, not a state. "Full habituation" would be a state, and I do not know of anybody who has truly experienced severe intrusive tinnitus who has then gone on to fully habituate, regardless of which definition one uses. On the other hand, I know many who have largely habituated to their great satisfaction and relief.

Quote:
4. Even when habituated, are you still supposed to avoid silent environments? I wasn't sure if that goal to avoid silence falls away at some point.

Avoiding silence is not a goal. Avoiding silence is part of a strategy for facilitating habituation. In my experience once folks have progressed to a point where they are comfortable and largely do not care about their tinnitus one way or another, they do not purposely try to avoid silence

Quote:
5. I feel impatient that a deeper level of habituation is not happening more quickly for me. I do use CBT techniques and they've been beneficial. I also know a person with tinnitus who said it took him two years to reach that "don't hear it unless you listen for it" level. Are there typical time frames / guidelines for habituation? Or is it highly individual?

Habituation is a passive process. You cannot force it. Trying to habituate is like trying not to think about a pink elephant. The harder you try not to think about a pink elephant, the larger it becomes in your mind's eye. That said, most folks do try to habituate, which is Strike One. Moreover, most folks do not employ an effective strategy for facilitating habituation, which is Strike Two. I suspect that you came here to this site to hopefully avoid Strike Three, which is tripping over your own feet. Looks like you are doing just fine in that regard. Don't rush things. And don't put a calendar on progress.

All the best with it.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Lucie14

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 #4 
That's interesting, Dr. Nagler. I wonder if part of my frustration stems from wanting to jump into the "not perceiving" mode when I am still working through the "not reacting" phase. I still am aware of my tinnitus quite a bit, but I'm not as reactive to it as I used to be, although as noted above I do still have some challenging days. Still, grateful for progress. Looking forward to your other answers, when you have time, esp around silence. Thanks so much as always!
Dr. Nagler

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 #5 
You are welcome.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Lucie14

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Posts: 22
 #6 
Thank you so much for these responses.

I can get a little confused over this:

1) Not trying to habituate vs thinking of pink elephant analogy. Ie, thinking about habituation will have the opposite effect.

2) We're supposed to employ effective strategies for habituation ... yet isn't that trying to habituate?

How I interpret this is to employ a strategy for habituation, but then don't obsess over the whole situation too much. Which is probably why, when I am busy and engaged and have a lot going on, the tinnitus is not as bothersome. : - ) If my interpretation is incorrect, do set me straight! Thanks!
Dr. Nagler

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 #7 
I can see where you might be confused due to my wording. Thank you for asking me to clarify.

Habituation is a passive process whereby one reacts to one’s tinnitus less and less over time. There are a number of effective strategies for facilitating that process. I support the use of these strategies where appropriate. When I say not to try to habituate, what I mean is do not actively try not to react to your tinnitus. The harder you purposely try not to react to your tinnitus, the bigger deal it becomes. Employing effective strategies allows for the passive habituation process to proceed unimpeded.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
Lucie14

Member
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Posts: 22
 #8 
Hi Dr. Nagler, I think I get it. Thanks for the clarification! Lucie14
Dr. Nagler

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 #9 
Glad to help.

Stephen M. Nagler, M.D.

__________________

The best way to find yourself is to lose yourself in the service of others.
- Mahatma Gandhi

No bird ever soared in a calm. Adversity is what lifts us.
-
David McCullough quoting Wilbur Wright
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Dr. Nagler's Tinnitus Corner is provided for education and information only. It is not intended for the purpose of providing medical care and should in no way substitute for appropriate in-person consultations with qualified healthcare professionals. By using this site, participants agree to hold Dr. Nagler and Atlanta Tinnitus Consultants, LLC harmless with respect to any loss, injury, claim, liability, or damage arising from following the postings herein.