Everything we see, hear and feel is created by the brain, using a combination of the sensory information we have coming in and predictions that it makes. 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.
Medically unexplained tinnitus, hyperacusis and misophonia
The hearing system uses information from the senses, including information from our ears and some from our eyes, which is why you can hear what someone is saying better if you can see their face. To create our perception of sound, the brain combines this sensory information with what it believes about the world to make a prediction about the sound we need to be aware of in our environment. This is why we can tell what someone is saying more easily if we know what they are talking about. The brain adjusts its sensitivity to sound and our perception based on its predictions and, if the brain believes we are in danger, this can lead to it 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 our environment are dangerous and to give us 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 provides us with a reference for gravity. It also keeps the visual world stable when we move. The balance system uses input from the vestibular system in the ears, from the visual system, and from proprioception (that is, the sense of position and movement of the body based on information coming from the muscles, joints and pressure receptors). It uses the signals from sensory inputs combined with what it believes about the world to make a prediction about our movements and where we are in space. When the system is working well, these signals are integrated in the brainstem at an unconscious level and, at any given time, those inputs are used to drive the muscles of the eyes and the body without us even thinking about what is going on most of the time.
Dizziness is a danger signal telling us that the brain is taking these inputs and that they are conflicting with each other, and it doesn’t know 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. Prediction is a difficult task and sometimes the brain’s prediction system can go wrong. Our brain is 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 this is interpreted as injury, danger or threat but actually that could be inaccurate. The brain is taking the evidence from the body and making it fit this view of injury and danger. Functional MRI scans of people with tinnitus, sound sensitivity and chronic dizziness with normal inner ear function and a diagnosis of PPPD show that the 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. It is natural to then respond to these symptoms with fear or frustration, which reinforces to the brain that they are dangerous and leads to them being amplified.
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
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.