There is agreement among experts that two paths link the auditory system with the emotional and autonomic systems. The first path includes brain centers involved in thinking, analyzing, verbalizing (conscious, cognitive processes) and the second path connects the auditory system with emotional and autonomic system at the subconscious level. While the “thinking” path is important at the initial, acute stage of tinnitus, clinical research points to the fact that with chronic tinnitus the subconscious path plays the dominant role. Therefore, paradoxically patients can suffer from tinnitus even if they are not aware of the presence of their tinnitus at a given moment! (It is similar to the situation when a person is dehydrated, without being aware why she/he experiences balance problems, headaches etc.). The tinnitus signal increases activation of the autonomic nervous system through this subconscious path and causes anxiety, feelings of panic, and general unhappiness.

These subconscious connections are governed by conditioned reflexes. In the case of conditioned reflexes the reaction to a given stimulus (e.g., tinnitus) occurs without the need to think and analyze the situation. Consider the Pavlovian dog experiment – when the bell is ringing, the dog is salivating, even if food is not given, because the dog was trained to associate the sound of the bell with food. To create a conditioned reflex it is enough that the signal (e.g., tinnitus) is happens at the same time as the person experiences a negative emotional situation. There is no need for causal association.

The subconscious brain works to a large extent independently from the conscious part of our brain. For example let’s imagine that we visit a country where by convention everyone drives on the left side of the road. We understand perfectly well that we have to stay on the left side of the road, that the buttons and switches from the windshield wipers and turn signals are on the opposite side of the steering wheel, we need to use our left hand to change gears, and we have to make wide right turns. This is all very easy to understand, but trying to actually drive in England is quite challenging! We would be very dangerous drivers in spite of knowing very well what we need to do. The problem is that we understand all of this at a conscious level while our driving is controlled by complex set of conditioned reflexes performed by our subconscious brain, and what we know consciously is not automatically transferred to our subconscious brain. It is possible to think about this as if we have two people in our head – one analyzing and thinking in words, and the other, which works at a subconscious level and makes its own decisions.

Therefore, even if we realize that the tinnitus sound is a consequence of some small disturbances in our hearing system, this does not help to remove the subconscious connections; thus special treatment is needed for this specific problem. Another aspect of the connections controlled by conditioned reflexes is the fact that we need some time to change, retrain them – it is easier to learn than to “unlearn” something (e.g., if we learned to play golf incorrectly or pronounce a word inappropriately it is more difficult to learn how to play correctly or pronounce the word correctly, than it would have been to learn how to play golf correctly or pronounce the word correctly from the start).

It is important to realize that all the processes, which are described above, reflect physiological functions of our brain. Therefore, the treatment of tinnitus we recommend is Tinnitus Retraining Therapy (TRT). The primary aim of TRT is to modify physiologic functional connections to enable retraining the brain to stop the strong and negative reactions to the benign tinnitus signal. It is a habituation-based method. Additionally, there are other treatment options available for tinnitus patients, some of which are also highly effective. The bottom line is that it is not necessary to suffer because of tinnitus!

Treatments, which include counseling, may bring relief to some people depending on the degree and complexity of the problem. Providing correct information and accurate answers to patients’ questions are the keys to success. “Standard-of-care” counseling with reassurance, demystifying tinnitus can be helpful to people who have concerns about tinnitus but are not significantly bothered by it.