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Kit suggested that I started a new thread on tinnitus, extracing postings from my earlier thread on Body Awareness. So here it is. Most of what is here will have been removed from the earlier thread to avoid duplication, but some will remain to keep continuity.

Jim: Here’s my essay on the differences between what I call the natural approach, and the biological approach, using tinnitus as an example. Its needs to be long, but we all know we need to get away from the sound-bite culture, so I am sure you will bear with me – and even read to the end.

Kit: “Let me illustrate my thesis by mentioning that I have severe tinnitus (to the extent of being functionally deaf in my L ear) but this is not any kind of problem for me (I have been a meditator for 30-odd years, and awareness and relaxation a special focus). In other words, my mind de-emphasises what could otherwise be maddening. The same techniques can be useful in all similar problems.”

Jim: First, some background. It is now clear that the great majority of cases of tinnitus are due to denervation hypersensitivity – i.e., when deprived of its normal input, the central nervous system generates its own activity instead.

Therefore although Kit has suggested the tinnitus made him deaf in the left ear, I suggest the causation was probably the other way round. There was probably some earlier hearing loss (maybe so little that it was not noticed), and the tinnitus developed as a result. The hearing loss then progressed further, so appeared to be the result, not the cause, of the tinnitus.

The second point I want to make about tinnitus is that many people find it very ANNOYING. It is like those sounds that may not matter to us at first (neighbours’ music, dripping taps, etc) but after a bit they get on our wick, and can become overwhelming. Part of this response is our feeling that the sound SHOULD NOT HAPPEN – but we are helpless in doing anything about it. And it does not need to be very loud for this to happen.

In the “natural” approach, this annoyance reaction, which drives the very negative effects of tinnitus, is uncoupled, by meditation or other techniques. The sound remains present, but has become neutral in its effects. This is clearly the method that Kit has used. The advantages of this method are that it needs no equipment or specialist medical input, and the methods developed can be applied to a wide range of situations. Very valuable indeed!

Until recently, this was the only approach available. Indeed, when I first developed my own tinnitus a decade or two ago, and went to a friend who was an ENT surgeon for an assessment, and his response was “Just put up with it. I can put up with mine and it doesn’t trouble me.” So it was clearly OK for him.

The trouble is, this does not work for many people. It did not work for me, much as I would have liked it to. And when people are told to fix something themselves, when they have come for help and clearly cannot fix themselves, then this can lead to despair, increased stress, and a worsening of their symptoms in a vicious spiral downwards. Tinnitus is sometimes described as so stressful that it leads people to suicide, though the statistics show this only happens in those who are also facing a lot of other stressors at the same time.

Luckily I knew therapy was available, and went straight round the corner to the next clinic and got it. This is called Tinnitus Retraining Therapy. For anyone reading this, who has tinnitus, this is what you should be putting into Google to find a practitioner. The logic, backed by data from animal experiments, is that every time we let tinnitus annoy us, the neural connections between the auditory pathways and the parts of the brain that signal annoyance get strengthened. Every time we have tinnitus and it does not annoy us, the connections get weakened. The basis of tinnitus retraining therapy is (among other things) to play a sound through headphones that sounds rather like the tinnitus, but not quite, at roughly comparable loudness, so we can hear both at once. The sound through the headphones does not annoy us, because we can control it if we want, and by directing our attention to that sound rather than the tinnitus, the neural pathways connecting the tinnitus to the annoyance parts of the brain get weakened. The result is that though we can often still hear the tinnitus once the headphones are removed, it does not annoy us any more. And because the neural pathways are getting weakened, the tinnitus might disappear completely – or, as commonly happens, come back briefly (and not annoyingly) only when our attention is drawn to it (by someone talking about tinnitus, for instance).

My guess is that Kit used meditation and other techniques to achieve the same uncoupling. Many people however need help to achieve this.

The next stage of my own tinnitus journey happened a year or so ago, when my hearing loss (probably as a result of ageing) progressed further, and under this extra challenge, the tinnitus returned. But I was already using the tinnitus retraining techniques on my own as a routine. How could I deal with this new challenge? Here I turned to my scientific training (and I was also inspired I should add by an article in the Weekend Australian that you might have seen, about an American called Moskowitz who conquered his own chronic pain through visualisations - this is also described in “The Brains Way of Healing” by Norman Doidge).

It is known that if an area of the brain is deprived of its normal input, neural connections from adjacent areas will invade and initiate their own activity (actually, the connections are probably there all along, but their activity is normally suppressed). In hearing, this means that if a part of the brain that normally responds to signals at say 8 kHz is no longer getting an input, neurones responding to say 6 kHz, will end up activating the area (much of the pioneering work on this was done at Monash).

So with the guidance of my audiogram, which showed a steeply rising hearing loss at 8 kHz, I made up a stimulus with its energy concentrated just below this frequency, using the free sound editing program Audacity. I took some music (rather repetitive guitar music) speeded it up so it sounded like a twittering (so it would be meaningless but have temporal fluctuations that would keep the system stimulated), shifted it in frequency and then filtered it, so all the energy was all in the 6 – 8 kHz band, and put it as a loop on my ipod and listened at a level just above detection threshold. I put it on to fall asleep at night, and lo and behold, the tinnitus went very quickly. So this showed how an increased understanding of the physiology could make a cure when other methods had failed.

There are a few interesting points I can make now. One is that when I first heard my new auditory stimulus, I felt “YES”! Somehow I felt very welcoming towards it. It was though the sound was an old friend, that I had been wanting to hear all along, and had been missing. I suggest that at long last neurones that had been deprived of stimulation were getting some, and this produced a welcoming emotional response. Similar reactions have been noted by others when their aberrant neural inputs have been corrected.

Second point – why can tinnitus be so very annoying? This may seem no-brainer, but once the question is posed, you realise, why is it so different from the other sounds that we hear all the time that do not annoy us? The reason comes down to the neurophysiology. The auditory system, like all other sensory systems, has different components. We have the specific system, which I can liken to a motorway. It is fast and efficient and its job is to get the signals analysed precisely and quickly so that they can be acted on cognitively with minimal delay. But the motorway pathways are surrounded by other pathways, more like country lanes. They are slower, meander, and connect with lots of other pathways (and to other sensory modalities as well). They also preferentially connect to the emotional systems, including attention and arousal which also means annoyance. For reasons peculiar to their cell biology, these pathways seem particularly sensitive to the loss of normal input, and so become particularly hyperactive when deprived. So any stimulus that does get in, will drive the “annoyance” response particularly strongly. This is why tinnitus can be so annoying.

Finally, do these findings suggest a drug treatment, so we can just pop a pill and forget about it? (no more hard work!) While animal studies have suggested drugs that might be useful, none in practice have turned out to be particularly effective, or without too many drawbacks. But it is quite likely that one day these studies will show an effective drug treatment.

So in summary how do I compare the “natural” and “biological” approaches? The natural approach is simple, low tech, and can potentially be applied to many different situations. However it takes time and discipline and not many people it seems can achieve it.

The biological approach needs input from professionals, and costs money, but is usually very effective, even for people for whom the natural approach has failed completely. And one can use it to derive variants (as I did) to deal with situations of varying difficulty. But both approaches have the same underlying logic (almost, anyway - my second approach was doing something different). One could say that the biological approach uses targeted baby steps, devised as a result of understanding the biology, to achieve the same result as the purely natural approach, and that the desired outcome is more easily achievable by a wider range of people.

Finally – and here I am going into deep water and may regret it. But why can some people make the natural approach work and others not? Clearly, practice and discipline come into it. But as well as that, there may be some underlying biological variables that we do not know about. My ENT surgeon implied that there was not an issue – dealing with tinnitus came naturally to him. He is (or was then) a nice, calm, social, well adjusted person who could stand a lot of stress – just what is needed in a surgeon who has to perform very delicate and sometimes life-threatening operations for hours on end (life-threatening when they do intracranial surgery). Very different from a scientist like me who has chosen another path, because it suited my own very different basic temperament. Is this a factor? I don’t know. However we do tend to make moral judgements about peoples’ responses to these situations, when in fact it may be driven by basic differences in biology (types of neurotransmitter enzymes inherited for instance).

As for a lit review on tinnitus, which Kit mentioned, a little book called "An Introduction to the Phyisology of Hearing" by one James O. Pickles has a few pages on it, though it is not at an introductory level (my little joke - when I was starting to study science, all the most advanced books seemed to be called "An Introduction to..." - implying now you're getting onto the REAL stuff).

Jim.

Kit: I would love to read your book; I just tried to order it from Amazon, but an error message was returned "we cannot ship to your nominated address". WTF?

 

Jim: First, some background. It is now clear that the great majority of cases of tinnitus are due to denervation hypersensitivity – i.e., when deprived of its normal input, the central nervous system generates its own activity instead.

Therefore although Kit has suggested the tinnitus made him deaf in the left ear, I suggest the causation was probably the other way round. There was probably some earlier hearing loss (maybe so little that it was not noticed), and the tinnitus developed as a result. The hearing loss then progressed further, so appeared to be the result, not the cause, of the tinnitus.

Kit: This very likely is true and I was going to make exactly the same point about plantar fasciitis: removing what I consider to be the necessary stimulation from one's feet by insulating them from the environment (shoes) is the cause: the brain/neural system needs this information, and 'looks harder' for it by turning up the volume on the signal from the plantar fascia. Hypersensitivity of the plantar fascia is the result. I wonder how much of EDS might be explained by similar mechanisms, and whether the Mast cell activation syndrome difference is the result of this, rather than the cause?

Yes please to starting a tinnitus thread, and cut and paste from the threads above. Re. my L ear: I think that both processes proceeded; in the sense that the loudness of the tinnitus increased as well as the deafness increased. One of the reasons I have not had my hearing tested for so many years is that I think the hearing aid technology that does allow one to hear better does not change the tinnitus. The retraining therapy you mention is of interest to me; perhaps we can talk about this some time.

 

(End of extract) Jim.

 

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Finally – and here I am going into deep water and may regret it. But why can some people make the natural approach work and others not? Clearly, practice and discipline come into it. But as well as that, there may be some underlying biological variables that we do not know about. My ENT surgeon implied that there was not an issue – dealing with tinnitus came naturally to him. He is (or was then) a nice, calm, social, well adjusted person who could stand a lot of stress – just what is needed in a surgeon who has to perform very delicate and sometimes life-threatening operations for hours on end (life-threatening when they do intracranial surgery). Very different from a scientist like me who has chosen another path, because it suited my own very different basic temperament. Is this a factor? I don’t know. However we do tend to make moral judgements about peoples’ responses to these situations, when in fact it may be driven by basic differences in biology (types of neurotransmitter enzymes inherited for instance).

Interestingly, you can make almost literally the same point about causation you made re:tinnitus here. He might have developed these qualities because he is a surgeon, not the other way around. In reality, a mix of the two is probably the case.

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@Kit " One of the reasons I have not had my hearing tested for so many years is that I think the hearing aid technology that does allow one to hear better does not change the tinnitus. "

The recommendation is that one gets an appropriate hearing aid. Without an aid, the deprivation of auditory input continues, so the central hypersensitivity tends to develop further.

Hearing aids are however horrendously expensive, costing the patient maybe 50 or more times the cost to the practioner (however the practitioner has to buy 100 at a time). This is partly a rip-off - however a lot of the overall cost of the aid is in the fitting, which needs care and skill. One issue is that audiologists like to push the most expensive highest-tech and most advanced aids that they can, for financial reasons. The more severe your loss, the more advantage an advanced aid can give you. However the people with the greatest hearing losses tend to be the most elderly, and they tend to get least benefit from these aids for multiple very basic reasons (such as not putting them in the ear properly, not keeping them clean, not changing the batteries, not keeping them recalibrated and adjusted).

The other point is that the more advanced the aid, the more carefully it has to be fitted and recalibrated. For some people (e.g. relatively younger people who will use their aids properly, adjusting them for each situation, and who turn up to their appointments for recalibration) this may be worth it.

Audiologists also like to push the most miniaturised aids, which are the most expensive, with the excuse that most people like that for cosmetic reasons. Personally, I'd have thought the very elderly who have so much else to cope with would not be particularly inflenced by that (and very miniaturised electronics produced in small quantities get very expensive). When my time comes I'd be quite happy with a big box on my lapel with a wire to my ear, as in the old days (and I'd be able to pick it up and point it at people in a crowd).

It amazes and horrifies me that I can buy a computer with many more times signal processing power than many hearing aids, for a tiny fraction of the price.

A year ago I was advising a friend, and found some audiologists/auditory scientists (I think in Melbourne) who I knew as responsible and respectable scientists, who had attempted to circumvent this rip-off as effectively as they could. Reasonably high-tech aids (normally costing several 000s of dollars fitted) were about $1000 a pair, and you got calibration and fitting programs to run on your computer to help you set them up (plus they would give telephone and online assistance). It seems they were trying to do the decent thing in an otherwise I am afraid rather corrupt industry. I wont look them up now, but will do so you (or anyone else) are interested.

Jim.

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  • 5 years later...
On 11/3/2016 at 3:13 AM, Jim Pickles said:

A year ago I was advising a friend, and found some audiologists/auditory scientists (I think in Melbourne) who I knew as responsible and respectable scientists, who had attempted to circumvent this rip-off as effectively as they could. Reasonably high-tech aids (normally costing several 000s of dollars fitted) were about $1000 a pair, and you got calibration and fitting programs to run on your computer to help you set them up (plus they would give telephone and online assistance). It seems they were trying to do the decent thing in an otherwise I am afraid rather corrupt industry. I wont look them up now, but will do so you (or anyone else) are interested.

A very useful discussion; I will tag with with "hearing loss' as well as with "tinnitus". [later; I see you have done this already; thank you]

My resistance to hearing aids is the relative crudeness of the current technology. I subscribe in many places, and I have been reading that a number of companies in the US are on the verge of releasing "non-medical" hearing aid technology that harnesses the power of one's smart phone to supercharge the hearing aids' tech.; this too seems like a no-brainer to me. And yes, the hearing aid industry might well be described as corrupt. 

I would be very interested in knowing more about the:

On 11/3/2016 at 3:13 AM, Jim Pickles said:

audiologists/auditory scientists (I think in Melbourne)

There was a company called whose name I thought was "Eye One" (but a search did not find it) that harnessed phone computing power to do the heavy lifting (and which also allowed tailoring of the devices' response curves using audio files that the phone stored) but it went broke. You've probably seen this, but some of the emerging ideas are canvassed in a generalist article here:

https://www.hearsoundly.com/guides/hearing-aid-trends

I think this field is wide open, and less expensive, cleverer tech will be much more common soon. The mistake that I think hearing aid companies have made is in pursuing the exponentially expensive process of miniaturisation so the aid will fit in-ear, when all the computing power in the world is on the phone in your pocket. As well, aids need microphones that sample the distortion of one's auditory canals (and I see one of the researchers in the referenced article has made that her focus). Improvements ahead, I think.

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I agree that the massive computing power that is in your phone is a wonderful way of providing a fully programmable, adjustable hearing aid at minimal (even no extra) cost. But this goes against the trend of miniaturisation (from the article): "I think hearing aids will continue to get smaller...". If that is important, and now that so many people have phones in their pockets and wireless earbuds I see a whole new field developing. I can get a sound analysis program on my phone for free or maybe $1-2 which is nearly as powerful as a spectrum analyser my work had to pay 8000 pounds for many years ago (equivalent to probably A$60,000 nowadays). I think it is highly likely that high quality hearing aid programs will soon be available for phones.

Why are companies keen on miniaturisation? Because it adds massively to the expense, and this means that they can charge a lot. This not only keeps their expensive shops running (and amazingly in Australia you dont need any qualifications to run a hearing aid shop) but also pays for the expensive fitting needed (see below). I haven't been following the field recently, but a few years ago I got the impression that more companies were offering cheaper self-help hearing aids (maybe with computer-aided adjustment).

However if any aid is to work at anything more than a basic level, it needs (1) frequency-sensitive amplification (i.e. more amplification for the frequencies where you have greater hearing loss), and (2) compression, offering more amplification for quieter sounds, and less amplification for louder sounds so that they do not become overwhelming. This compression needs to be different for every frequency band. Offering this is a small package is getting complicated, but easy in a larger package. These parameters need to be adjusted carefully and individually for each person, and ideally readjusted regularly (every 6 months or so). It could theoretically be done via computer (and the company I mentioned in my earlier posting did that) but that needs a certain amount of computer-savvyness which many of the potential users may not have (my dad would even forget to put his batteries in). Hence for many people the need for expensive technician-assisted fitting and refitting.

Another point is that it would need external microphones (one for each ear). The sound from the phone microphone in your pocket would be poor quality and muddy. Ideally, the microphones would be mounted in the ears, so that you can look towards the speaker as in real life and hear the sound as coming from that direction. I wonder if it is possible to get wireless speaker/microphone combinations to fit in the ear (if not, they will probably come soon). Unless they are produced in very large quantities, they would be expensive if high quality (which they would need to be, so as not to introduce further distortion which you could do without) – maybe a hundred dollars or two each.

As for making it individual for each ear shape, as mentioned in the article, I see that as a minor side issue (people are always trying to make their own slant on things). Yes, recordings with a microphone in an artificial ear sound more natural if the artificial ear is a copy of your own, but this could be programmed into the phone if it was an important factor (and I suspect you would adapt very quickly to any new configuration). Another thing is directional hearing. Left/right is done by comparing the two ears, which is why two microphones and two speakers are best for that. Up/down and in-front/behind comes from subtle changes in resonances due to the shape of the outer ear – I’d have thought that this would be a minor issue compared with all the other things that a hearing aid listener would have to put up with.

Note that the bionic ear electronics include a lot of special programming to make all this easier for you (e.g. enhanced acoustic separation of left/right channels), and it would be possible to provide similar programming in the larger package of a phone.

So the future? In-ear (or on-ear) wireless microphone/speaker combinations, communicating with a mobile phone which has a special program, adjusted initially via computer for savvy users, or a technician for non-savvy users. Cost: a few hundred dollars (plus phone and technician time for those who need it).

The company in Melbourne that I mentioned earlier is now at https://blameysaunders.com.au/

It was founded by well respected auditory colleagues, well known in the field, who earlier had worked on the Bionic Ear in Melbourne.

Not mentioned earlier in the thread, probably because they were developed afterwards, are my own pages on tinnitus, with some self-help principles and therapy sounds (https://www.jimpflex.com.au/tinnitus/). These sounds are optimised for dealing with tinnitus resulting from high-frequency hearing loss. They have helped some people enormously (see "one of the few miracles in my life" at https://www.jimpflex.com.au/tinnitus/tinnitusstory.html). Cliff said he had been suicidal. However it does not work for everyone.

How does all that sound? Very best wishes to you all,

Jim.

 

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On 1/25/2022 at 5:52 PM, Jim Pickles said:

I wonder if it is possible to get wireless speaker/microphone combinations to fit in the ear (if not, they will probably come soon).

Agree completely re. one of the companies that article pointed to who already has these, as part of their attempt to sample, and correct, distortion caused by individual ear canal shapes—this is not likely to be a major advance for the reasons you give. But an Australian company, Røde, make the superb "GO II" miniature transmitters and receivers which use something they call a "Pin Mic" (which we already use to record broadcast quality sound with the same transmitters and receivers), and the diaphragms on these are only 2–3mm across—advances in making these smaller quality microphones will allow what you point to, I feel.

On 1/25/2022 at 5:52 PM, Jim Pickles said:

So the future? In-ear (or on-ear) wireless microphone/speaker combinations, communicating with a mobile phone which has a special program, adjusted initially via computer for savvy users, or a technician for non-savvy users. Cost: a few hundred dollars (plus phone and technician time for those who need it).

Agree completely. And thanks for the links, both to Blamey Saunders, and your work on tinnitus; I will look/listen to this later this week. Thanks for replying in such detail!

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