Tinnitus and anxiety: how the loop works and what helps

A common pairing

Tinnitus and anxiety often come together. The NHS lists anxiety and depression among the conditions tinnitus is often linked to, and the NIDCD notes that in severe cases tinnitus can lead to anxiety or depression. A 2016 review by Pattyn and colleagues, based on 117 papers, reported a 45 percent lifetime prevalence of anxiety disorders in the tinnitus populations studied. If the sound makes you tense, you are far from alone, and it says nothing about your strength of character.

The loop, step by step

Psychologists describe tinnitus distress as a loop. McKenna and colleagues proposed a cognitive-behavioural model in which tinnitus becomes distressing when a person holds overly negative thoughts about it. Those thoughts raise arousal and emotional distress, and they drive selective attention, constant monitoring of the sound and counterproductive safety behaviours. These in turn lead people to overestimate how loud and intrusive the tinnitus is, which feeds the negative thoughts. The sound itself may not change at all; the loop around it does.

Why checking makes it louder

One engine of the loop is monitoring: listening for the tinnitus to find out whether it is still there, whether it is worse today, whether it has changed. According to the same model, selective attention and monitoring can make the tinnitus seem louder than it would otherwise. Each check feels reasonable on its own, but together they keep the sound at the centre of attention.

Safety behaviours that backfire

Safety behaviours are what people do to protect themselves from a feared outcome: avoiding quiet rooms, cancelling plans, never being without a masking sound, wearing earplugs in ordinary situations. The model notes that such behaviours can inadvertently maintain or worsen worry, and can directly change how the tinnitus is detected, for example by manipulating the sounds around you. Background sound is useful, but it helps more as support than as a place to hide.

What the evidence says about CBT

Cognitive behavioural therapy (CBT) targets exactly this loop. A 2020 systematic review by Fuller and colleagues, covering 28 studies and 2,733 adults, found that CBT may reduce the impact of tinnitus on quality of life compared with no intervention or a waiting list, by about 11 points on the 0 to 100 Tinnitus Handicap Inventory, against a minimal clinically important difference of 7 points. The certainty of that evidence was low. Compared with no intervention, the review was uncertain whether CBT reduces anxiety; compared with other active treatments, CBT may reduce depression and anxiety. CBT does not aim to remove the sound. It aims to change its impact.

What the guidelines recommend

The US clinical practice guideline by Tunkel and colleagues recommends CBT for people with persistent, bothersome tinnitus, and recommends against antidepressants, anticonvulsants, anxiolytics or intratympanic medications for the routine treatment of the tinnitus itself. The NHS explains that a GP or specialist may refer you for talking therapy such as CBT, to change the way you think about tinnitus and reduce anxiety, and that digital CBT, delivered through an online programme or app, is usually offered first.

Anxiety is worth treating in its own right

Pattyn and colleagues recommend screening for and treating anxiety disorders in moderate to severe tinnitus, noting that managing them could in theory improve how the tinnitus is experienced, while further research is needed. Whatever happens to the sound, anxiety that disturbs your sleep, work or relationships deserves care. The NHS advises seeing a GP if tinnitus is affecting your sleep or concentration or making you feel anxious or depressed.

Name the thought, then test it

The NIDCD describes CBT as learning to identify the negative thoughts that cause distress and to change your response to them. In practice, that starts with noticing the specific thought behind a spike of fear, such as “This will never stop” or “I will never sleep again”, and treating it as a hypothesis rather than a fact. What happened the last time you thought that? Did you sleep at all? The aim is not forced optimism but a more accurate picture, which is usually less frightening than the thought.

Check less, on purpose

Decide in advance when you will pay attention to the tinnitus, for example once a day when you fill in a short log, and treat the rest of the day as off duty. When you catch yourself checking, notice it without judgement and bring your attention back to what you were doing. The NHS advises not focusing on tinnitus, since this can make it worse, and suggests that hobbies and activities may take your mind off it.

Calm the body as well as the mind

The NHS suggests trying to relax, for example with deep breathing or yoga, and looking for ways to improve sleep, such as sticking to a bedtime routine or cutting down on caffeine. It also advises avoiding total silence and says that soft music or sounds may distract from the tinnitus. None of this silences the tinnitus, but it works on the arousal that the model places at the heart of the loop.

Keep living around the sound

Avoidance shrinks daily life and gives the tinnitus more importance. Gradually return to the quiet places, social plans and activities you have been avoiding, starting with the easiest, with a low background sound if that helps at first. Support counts too: the NHS suggests joining a support group, since talking to other people with tinnitus may help you cope.

When to get help now

See a doctor if tinnitus is affecting your sleep or concentration or making you feel anxious or depressed, as the NHS advises, and ask about tinnitus-focused CBT. If you ever have thoughts of harming yourself, contact emergency services or a crisis line straight away. That comes before anything else in this guide.

Where Tacet fits

Tacet is not a therapy and does not treat anxiety, but it can support the practical side of this guide. Its daily journal asks one question, how much the tinnitus bothered you from 0 to 10, with optional tags such as a stressful day or a bad night, so you can check once a day instead of all day and look at your pattern over weeks. Its sounds can sit just below your tinnitus as support rather than cover, and its night timer fades out instead of stopping abruptly. The journal exports as a PDF for an appointment with a doctor or therapist.

Further reading

• McKenna, Handscomb, Hoare & Hall (2014), A scientific cognitive-behavioral model of tinnitus: Novel conceptualizations of tinnitus distress, Frontiers in Neurology
• Fuller et al. (2020), Cognitive behavioural therapy for tinnitus, Cochrane Database of Systematic Reviews
• Tunkel et al. (2014), Clinical Practice Guideline: Tinnitus, Otolaryngology–Head and Neck Surgery
• Pattyn, Van Den Eede, Vanneste, Cassiers, Veltman, Van De Heyning & Sabbe (2016), Tinnitus and anxiety disorders: A review, Hearing Research
• NHS · Tinnitus
• NIDCD · Tinnitus