Everything we see, hear and feel is created by the brain. The brain has a set of expectations, and when sensory information comes in, it compares the information it has received to these predictions. This is more efficient than trying to analyse the information coming in from scratch. These predictions are based on what the brain knows, its inner learnings about the world. These learnings are based on our experiences, both perceptually and psychologically. The predictions also have an effect on our attention and what we notice in the world; for example, if you were walking through a forest full of sticks, you probably wouldn’t take much notice of the sticks unless you were told that there were lots of snakes in the forest. In this case, you would notice all the sticks and you might make a mistake and think one of them was a snake!
Medically unexplained tinnitus, hyperacusis and misophonia
We often think of hearing as something that happens in our ears, but in reality, we hear with our brain. To create our perception of sound, the brain’s hearing system compares its predictions about the sound we need to be aware of to the information from the senses. This information comes mainly from our ears but also from our eyes—which is why speech is easier to understand when we can see a speaker’s face. These predictions also help us follow conversations more easily when we already know the topic.
The brain adjusts its sensitivity to sound and decides which sounds we perceive based on its predictions and, if the brain believes we are in danger, this can lead to someone becoming aware of the normal background sounds in the hearing system and the head and processing them as a danger signal. This is the cause of medically unexplained tinnitus. In people with hyperacusis and misophonia, the brain starts to predict that normal sounds in the environment are dangerous and to give them danger signals in response to them, such as discomfort, pain or a strong emotional reaction.
Chronic dizziness with diagnosis of PPPD, vestibular migraine and MdDS
Balance allows us to control our posture and stabilise the body. It allows us to stay stable when the world moves or when we move or a combination of the two and it gives us a constant reference for gravity. It also keeps the visual world stable when we move our head or body. The balance system brain creates predictions of where we are in space and expected motion based on past experience. It then compares these predictions to sensory input from three sources:
· The vestibular system in the inner ears, which senses motion and head position.
· The visual system, which tells us how the world is moving relative to us.
· Proprioception, the sense of body position and movement from signals in muscles, joints, and pressure receptors.
When the system works well, this information is integrated in the brainstem at an unconscious level and, at any given time, the balance system automatically adjusts the muscles of the eyes and the body — keeping us steady without us having to think about it most of the time.
Dizziness is a danger signal that happens when the brain’s predictions and sensory inputs conflict, leaving it uncertain about where the body is in space. It is a very strong and scary danger signal. This is because, evolutionarily, not knowing where the body was in space and not being able to control posture and stability was very dangerous as it made you vulnerable to predators and potentially unable to get food.
Danger signals
Danger signals are designed to guide our behaviour and help us to avoid threats. To keep us alive, they have to be predictive as, if we only responded to threats as they arose, we wouldn’t live long. But prediction is a difficult task and sometimes the brain can get it wrong. Our brain works like a detective trying to figure out what is happening in the world and in our bodies but it has limited information. It has signals coming from the body and, based on those signals and its beliefs and expectations, it makes a guess as to what’s happening. Sometimes it interprets the evidence as injury, danger, or threat, even when that isn’t actually the case. In these moments, the brain can take the signals from the body and fit them into an inaccurate prediction of harm.
Functional MRI scans of people with tinnitus, sound sensitivity, and chronic dizziness with normal inner ear function and a diagnosis of PPPD, show that their threat response is highly activated. When the threat response is activated and the brain believes we are in danger, it is more likely to give us danger signals to protect us from harm. It’s a bit like having a car alarm that’s so sensitive it goes off when a leaf falls on it. Your brain is trying to keep you safe, but it’s overreacting. When we react to these symptoms with fear or frustration, the brain takes it as proof that the danger is real—and “turns up the volume” on the alarm, making the symptoms feel even stronger.
Are the symptoms real?
All tinnitus, hyperacusis, sound sensitivity, dizziness and pain is real and these symptoms are not being imagined. Whether there is structural injury or whether the brain is misinterpreting signals from the body, the pain is processed the same way. A functional MRI study found that the same areas of the brain light up when people experience pain from a hot probe and when they are hypnotised and pain is induced through suggestion. The study found that these areas of the brain were not activated when pain was simply imagined.
Treatment methods (Neuroplastic Recovery Therapy)
In order to recover from these symptoms, we need to teach the brain that the signals it is receiving from the body are safe and that you are safe in the world. Teaching your brain that the signals are safe can involve learning more about the processes involved, observing the symptoms through a lens of safety (somatic tracking), responding differently to the symptoms and gradual reduction of avoidance. Teaching your brain that you are safe in the world includes a combination of techniques such as using cognitive and physiological messages of safety, emotional processing to establish more safety in the nervous system, creating time for self-care and setting boundaries with others.
Chronic pain, chronic tinnitus, sound sensitivity and chronic dizziness are all neurophysiologically similar. Dr John Sarno’s work has helped many people to recover from debilitating chronic symptoms which were not caused by a structural problem in the body. He referred to these conditions as Tension Myositis Syndrome/ Tension Myoneural Syndrome (TMS). Others have gone on to develop and expand upon his methods. Studies have shown that Pain Reprocessing Therapy1 (PRT, developed by Alan Gordon) and Emotional Awareness and Expression Therapy2,3 (EAET, developed by Dr Howard Schubiner) can aid in teaching the brain to process sensory information correctly, helping people to reduce and recover from chronic symptoms.
My approach is based on a combination of these methods alongside other relevant techniques and audiological tools and knowledge. I have also trained in Accelerated Experiential Dynamic Psychotherapy (AEDP) to gain additional skills to help people to process emotions, enabling them to become more resilient to everyday life stressors.