March 26, 2025 • 31 mins
Why can some people completely forget about their tinnitus when engaged in challenging activities, while others remain painfully aware of it no matter what they do? The answer lies in our brain's complex attention systems, according to Dr. Grant Searchfield.
In this illuminating conversation with host Dr. Douglas L. Beck, Dr. Searchfield unpacks his groundbreaking scoping review on attention's role in tinnitus management. While most practitioners acknowledge attention's importance, Searchfield discovered a surprising gap—very few studies actually measure attention changes or make them a central treatment focus. This oversight may explain why tinnitus treatments work differently for different people.
When tinnitus first appears, our brain's survival mechanisms automatically flag it as important. This isn't just psychological—it involves neurological changes in how our auditory system connects with other brain regions. Dr. Searchfield explains that effective treatment must address both conscious attention (what we choose to focus on) and automatic attention (what our brain prioritizes without our control).
The conversation takes fascinating turns through various treatment approaches, from traditional sound therapy to cutting-edge bimodal stimulation that pairs auditory with tongue or visual stimulation. Dr. Searchfield makes a compelling distinction between passive attention (having background sounds playing) versus active engagement (deliberately focusing on alternative sounds or activities). The latter appears significantly more effective, similar to how active learning outperforms passive observation in education.
For anyone struggling with tinnitus or clinicians treating it, this episode offers transformative insights into why combining treatment approaches might be more effective than relying on a single method. The future of tinnitus management likely lies in personalized therapies that target multiple attention pathways simultaneously.
Subscribe to Hearing Matters for more breakthrough conversations that bridge hearing science with practical applications. Have you noticed how your attention affects your tinnitus?
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Blaise M. Delfino, M.S. - (00:19):
Thank you to our partners.
Sycle, built for the entirehearing care practice.
Redux, the best dryer, handsdown.
Caption call by Sorenson, Lifeis calling.
CareCredit, here today to helpmore people hear tomorrow.
Fader Plugs, the world's firstcustom adjustable earplug.
(00:41):
Welcome back to another episodeof the Hearing Matters Podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Dr. Douglas L. Beck (00:56):
Good afternoon.
Welcome to the Hearing MattersPodcast.
This is Dr Doug Wasbeck, andtoday I'm interviewing an old
friend of mine, dr GrantZurchfeld, and he has a new
paper on the scoping review ofthe role of attention in
tinnitus management, and I foundthat article to be fascinating
and encompassing of so manythings.
So, grant, first of all, thanksfor being here today.
Dr. Grant Searchfield (01:16):
Yeah, pleasure to be here, Doug, and
always great to chat with you.
Dr. Douglas L. Beck (01:19):
And since you're in New Zealand, I should
say thanks for being heretomorrow, because we're day
ahead of us.
Dr. Grant Searchfield (01:24):
A bit of time traveling Doesn't hurt.
Dr. Douglas L. Beck (01:28):
Give me the essence of the paper, the
scoping review on the role ofattention, and then I want to
compare that to a few other moretypical analysis and treatment
modes for tinnitus.
Dr. Grant Searchfield (01:40):
The purpose for setting out to do
this is we've been working inthe space of attention and
tinnitus from a point of view oflooking at how it affects
severity, but also dating backto 2007, looking at therapies
that might harness attention totry and change the brain, and so
it was timely for us to have alook at the overall literature
(02:03):
and find out what was going on,and so we did a search of a
number of different databases,looking primarily at the role of
attention in therapy, asopposed to the role of attention
in tinnitus generally.
So our search terms weretinnitus, therapy, treatment and
(02:24):
attention.
Terms were tinnitus, therapy,treatment and attention, and the
goal was to try and identifythe place, the role that
attention had in differenttreatments, how it was being
measured, the strength of theresearch, where the gaps were.
So that could help drive usforward as well in our own
endeavors.
Dr. Douglas L. Beck (02:42):
Yeah, and when I'm looking through the
literature, we don't generallypay a lot of attention to
attention, right?
I mean we're presuming we haveattention when we're engaged in
tinnitus retraining therapy orif we look at progressive
tinnitus management, but wedon't speak specifically about
attention and what you've donehere.
(03:02):
Very interesting.
You say difficulties withattention are commonly reported
by people with tinnitus andattention contributes to
tinnitus' salience andsubsequent disability.
So tell, me about that.
Dr. Grant Searchfield (03:17):
Yeah, well, I think, simply, most
people recognize that if you payattention to something, it
becomes worse.
So that's fairly obvious.
And I think people might saywell, you know, this is
searching something thatactually you know, everybody
knows.
But tension is complicated andit's not necessarily a process
(03:42):
that we have to apply thought to.
Some of this is automatic.
Some of it involves the signalbeing important, unimportant how
the brain reacts to these sortsof things.
So when we talk about salience,what we mean is it is an
important signal.
Is it there that the brainshould attend to it?
And when we talk about survivaltype of mechanisms, we all want
(04:05):
to be aware of threateningsounds in our environment and
hearing is our survival sense.
Right, we can hear aroundcorners, we're aware of sound
24-7.
So our hearing system iscontinually on alert, but it
can't listen to everything and alot of its processing has to be
(04:26):
automatic and filter outdifferent things.
But in the case of tinnitus,when that starts, the brain has
great difficulty letting it goand it does draw attention, both
attention that is under ourcontrol to a certain degree, but
also attention that's automaticand driven by these survival
(04:48):
type of mechanisms.
So the need was really toexplore that, because you're
quite right, we take it somewhatfor granted that attention has
a role here, and even some ofthe articles that we reviewed
mentioned attention, but theydon't actually measure it, and
(05:09):
so we really wanted to say, okay, people are saying that
attention is important fortinnitus therapy.
How and does it change withtherapy?
Because if it did well, that'sobviously an important indicator
for something you should focuson.
If it didn't, something else ishappening.
So we looked at the literature.
(05:31):
Overwhelmingly there wasn't alot of great detail.
As you said, some of thebiggest studies that were
undertaken, ostensibly lookingat attention, didn't have very
good measures of attention, butthen others were reasonably
comprehensive, using behavioralmeasures, questionnaires, but
(05:53):
also objective measures that arerelated to measuring attention
using MRI and EEG and the like.
Dr. Douglas L. Beck (06:02):
And when I read your paper I noticed that
you did a number of things andyou reported on Stroop effects
and you reported on what happensto the attention level when
somebody is working on a puzzleor a difficult challenge.
Dr Sertfeld, in your work youactually did the Tower of Hanoi
study, which is more of a totalmind involvement and you have to
(06:24):
be attending to it very, verycarefully, like a Stroop test or
like the game Jenga.
You have to totally focus ifyou're going to succeed.
So tell me about that.
What did you do?
Dr. Grant Searchfield (06:34):
Yeah, well, in this case, Doug, we
were reviewing some work byTinnit Sanchez, actually in
Brazil, who had done thisparticular piece of work in
Brazil.
Who had done this particularpiece of work?
And it's really a variation onthe very famous Haller and
Bergman experiment from the1950s.
Haller and Bergman researchedwhat people would experience if
(06:57):
they went into a soundproof room.
You know they said come intothis room.
And then they asked peoplewhether they heard sounds.
Now, most people heard soundthat wasn't there and they
reported sounds very much liketinnitus.
In their study, people wereunoccupied, people engaging in a
(07:22):
task modified their awarenessof these internal sounds when
they were in that quietenvironment and what it found
was that if you were unoccupied,your attention was lingering
around you're more likely tohear the tinnitus.
If you're engaged in a physicalactivity you know, busy,
(07:44):
solving a puzzle then you areless likely to report it.
Busy work lives who haveretired recently and they're
less occupied, but they suddenlyreport tinnitus.
(08:10):
You question them.
You say, well, how long haveyou had tinnitus?
I've had it for a long time,but it's really now that it's
been a problem.
And you explore that a littlebit, they say, well, when I'm
busy doing something, it's notso much of a problem.
They say, well, when I'm busydoing something, you know, it's
not so much of a problem.
And that comes back again tothat perhaps obvious aspect of
tinnitus and attention.
(08:31):
But the less obvious aspect ofit is whether we can train that
so people don't have to beactively engaged, whether the
brain can let go of tinnitus,reset itself, adapt and not
focus on the tinnitusautomatically.
Now some of that isn't undertop-down brain control, it's
(08:53):
more basically this primitiveletting the sound through
because it's important.
So each level of the brain thatapplies a different sort of
processing to the signal isreally important there.
And really what we'reinterested in is there are all
sorts of ways of applyingtreatments, as everybody knows.
When they are applied withattention as a measure of change
(09:19):
, how effective are they inchanging attention?
And also, did a change inattention relate to a change in
tinnitus?
A little bit of a chicken andegg scenario.
We can't show one causes theother, but we're really
interested If tinnitus improveddid attention vis-a-vis?
(09:41):
And a number of studies showedthat.
Some studies quite convincingly, others less so.
Dr. Douglas L. Beck (09:49):
And when you talk about these other
studies, you're talking aboutsome fMRI studies, some EEG
studies, transcranial magneticstimulation, all these things
right.
Dr. Grant Searchfield (09:57):
Yeah, so we looked at, we broke it down
to the particular study type.
Many of the studies usedbehavioral measures.
You mentioned the Stroop test,which is the one where you see a
color and it's got the speltword which may or may not agree
with the color, and the brainhas to take time to process that
(10:20):
.
So tests like that and otherswhere we're looking at changes
in the brain, particularly partsof the brain that are typically
associated with attention, andthe best studies of course
combine both, because that'sreally really powerful.
One of the downsides of, ofcourse, having all these tests
(10:41):
is it's difficult to do largestudies right.
So when we looked at theliterature, the largest studies
were generally in the space ofpsychological interventions,
particularly perhaps cognitivebehavioral therapy.
They had large numbers ofparticipants but they very
rarely did any objective measure, so they were very seldom.
(11:04):
Did you see any measure of MRI,eeg or other objective measure,
whereas tasks that perhaps hadfewer participants but were more
focused on attention, soundtherapy and perceptual training,
they often combined a measureof attention, a behavioral
(11:28):
measure, a measure of tinnitusand perhaps either MRI or EEG.
Dr. Douglas L. Beck (11:36):
Music therapy in particular.
Dr. Grant Searchfield (11:37):
Well, yeah, now music therapy is an
interesting one here.
So music therapy also wasinvestigated quite a bit with
regards to the depth ofinformation.
Investigated quite a bit withregards to the depth of
information.
Now again for the listeners.
When we talk about musictherapy in this context, it's
(12:00):
not just about listening tomusic, because music therapy is
almost more of a psychologicaltherapy than a typical sound
therapy for tinnitus, becauseit's about engaging in the
production of the sound andunder the guidance of a
therapist.
So that certainly was one thatpulled out as slightly separate
(12:21):
from these other broadcategories as investigating
attention.
So the areas where there was astrength of information on
attention were sound-based andperceptual training therapies.
They did tend to have smallernumbers of participants.
Studies that suggested thatattention was playing a big role
(12:46):
often had larger number ofparticipants but fewer
investigations and obviouslythere's a trade-off here in
these sorts of studies lookingat what you can do with a
certain number of resources.
But, yeah, quite fascinating.
And you know we started outlooking at I was around about
(13:06):
500 articles that we surveyedthat had tinnitus attention in
therapy you know as key things.
Dr. Douglas L. Beck (13:13):
That's a lot of studies.
Dr. Grant Searchfield (13:14):
Yeah, but then we narrowed it down and we
ended up with less than 40 thatreally investigated that in any
detail.
So it shows you perhaps theassumptions that attention is
important, but there hasn't beena huge amount of research
undertaken on it.
Dr. Douglas L. Beck (13:32):
But you know, this is fascinating in so
many respects because you couldsay how this relates.
Well, I'll ask your opinion.
So how does attention relate to, let's say, trt and then let's
talk about PTF?
Do you see a difference betweenthose two with regard to
attention?
Dr. Grant Searchfield (13:48):
Well, I think that almost all therapies
would assign some role forattention.
When it comes to thenitty-gritty on how that
attention is changed, forexample.
That's where the differencesare whether you're operating on
a psychological level, alearning level or a sensory
(14:11):
level, and probably you knowit's actually the combination of
these things which is thereally the secret, secret recipe
.
So we know, for example, withtinnitus retraining therapy, the
idea is that we need tohabituate, both in terms of our
reactions, so we need to notreact as strongly to the
(14:31):
tinnitus as what we would whenwe find an annoying problem.
And clearly attention has arole there.
And, to a smaller degree, alsothe habituation of perception.
And this is where attention canhave quite a nuanced role in
modifying that, in changing thatand what that actually means
(14:55):
and how the brain actuallyadapts to focus.
And we think of attention assomething that's sort of on the
psychological domain.
And you know we controlattention.
We can attend to it, we cannot.
You know we attend to a soundthat's threatening, like the
sound of an ambulance siren.
You know we automatically reactto that, while we don't to
(15:17):
something quite benign, like thesound of our car engine or the
wheels on the road yeah, this isan important point that you
bring up in the paper is thatyou have to learn what to attend
to.
Dr. Douglas L. Beck (15:31):
We generally attend to human speech
and we uh, you know we have inthe states we call it hvac
heating, ventilation, airconditioning systems.
Right, so if you use that, or arefrigerator, or a 60 cycle,
you know, or an incandescentbulb, those make sounds but we
tune them out and that's, that'sbased on learning.
You know that they are noninjurious or non dangerous, non
(15:52):
threatening sounds, so you tunethem out and you pay no
attention.
And this, this point, I think,is so important in tinnitus
management because we areactually it's a little bit you
know, maladaptive.
We're focusing on a sound that'sprobably always there, more or
less, but we are attending to it, which, as you said earlier,
once we focus on it, we attendto it, we tend to perceive it
(16:15):
more dominantly.
Dr. Grant Searchfield (16:17):
Yeah, absolutely, and this is a very
well-entrenched system.
It's our mechanism that we goabout surviving our world.
We need to make decisions onwhat to attend to and what not
to attend to, because we can't Ican't attend to everything when
tinnitus comes on because it'sunusual, we haven't necessarily
(16:37):
experienced it.
We can't link it to somethingin our environment, naturally,
without our own focusedattention on it, innate
attention, just what ishappening for our survival means
that we become aware of it.
Now, if we are an anxiousperson, we might attend to it
(16:57):
even more, but even if we aren't, something that's annoying and
threatening in our environment,it's important for us to attend
to that.
So you mentioned, for example,the way that we learn.
So you know, naturally ourhearing system learns from our
experiences.
(17:18):
You know, when we're in ourmother's arms, when we're
crawling along the floor, whenwe're falling over things, when
we're interacting with things aswe grow up, when we begin to
listen to music, all thesethings we're learning and the
brain is changing.
So you know, it's important tounderstand, you know this
concept of neuroplasticity andlearning.
(17:39):
And so when we are learning,the brain is adapting, it's
organizing itself into anefficient manner, as is possible
, into an efficient manner as ispossible.
So when there is a change tothat, we have this tension, but
(17:59):
there's this change inplasticity as well and the brain
modifies itself in order to beable to hear and react
appropriately.
So you mentioned the sound of alight, an incandescent light,
for example.
Now, if we'd learnt, we'd grownup, that that sound was a
warning signal, we wouldn't beable just to sit there and say,
oh, that's just a light, youknow, I'm fine.
(18:20):
We just wouldn't be able to.
Our bodies wouldn't allow us todo that.
So that reaction, thatautomatic reaction to a sound,
that Might seem quite benign ifI say it to you, but actually
because it's internal, it'sconsistent, it's ongoing, you
can't escape it, it takes onunusual importance.
(18:43):
Now, the good thing, if there isa good thing, is the fact that
this plasticity can, of course,change.
It can be reversed or modified.
Course change.
It can be reversed or modified.
So just as we can become betterat hearing tinnitus, we can
(19:09):
also become poorer at hearing it.
But in order for that to happen, a lot of these mechanisms that
the brain automatically puts inplay from a survival type of
perspective has to be adjusted,and this is not under
necessarily willpower, so youcan't necessarily say I'm not
going to attend to this Right.
There are innate mechanismsthat we need to be able to
(19:31):
modify in there.
Some people are able to do thatbetter than others.
Some people need assistance inthat.
Dr. Douglas L. Beck (19:38):
Dr Sertsch, tell me about bimodal
stimulation.
When you have stimulation onthe tongue and auditory
stimulation, how does that workand fit in with the tension?
Dr. Grant Searchfield (19:47):
Well, I guess what we have to say is
that bimodal stimulation, bydefinition, is the combination
of more than one form ofstimulation and at the moment
there is one particular productavailable quite widely in the
United States that uses tonguestimulation and sound
stimulation.
There are other experimentalmodes that use neck stimulation
(20:11):
and sound stimulation, or soundstimulation, visual stimulation.
So these are all bimodaltherapies and they each have a
different mechanism that they'retrying to promote.
Generally, what we're saying is, if you're using multiple modes
, you're building on getting thebenefit of using two methods,
(20:33):
so two is better than one, threemight be better than one and
that they can be used toreinforce the primary mode of
stimulation.
The goal and the physiologythat's trying to be changed
there will depend both on soundthat's used, if sound is used,
but also the form of stimulation.
(20:55):
And it's a little bit uncertainhow these are modifying the
brain, because often there isn'tthe objective evidence to show
that the behavioral changes,what's causing those.
But essentially, what you'retrying to do is you're trying to
promote change within onesystem with stimulation of
another.
So you're answering to do isyou're trying to promote change
(21:16):
within one system withstimulation of another, so
you're answering to the secondone.
Dr. Douglas L. Beck (21:20):
Yeah, it's an attention-based mechanism
that is helping to relievetinnitus.
Dr. Grant Searchfield (21:25):
Yeah, so, for example, we know.
An example that's easier toperhaps understand is when we
use vision and hearing right.
Often we use hearing to gainour attention, but the vision
reinforces or helps to navigateour word and confirms what we're
(21:49):
actually hearing.
In the case of vision and in thecase of vision, sometimes it
will dominate the hearing.
So if there's a strong visualimage that contradicts the
hearing, sometimes that willplay.
So our senses will work in alltogether.
And when there's anincongruence between the two,
(22:11):
such as tinnitus, where there'ssound without vision of a
sound-making thing, this iswhere our sensory system can
particularly come out of whack.
So what we can see in thedifferent therapy types is
there's different ways that youcan affect attention.
Right, we can affect attentionto tinnitus by making the
(22:34):
tinnitus not audible.
So by masking all right ormasking another sound there may
draw attention away from thetinnitus.
So that's a passive process.
But we can also use training,where the person is actively
instructed and engaging in notlistening to the tinnitus and is
(22:58):
rewarded for not listening totinnitus and is if they do hear
to tinnitus, they're notrewarded for it.
And this sort of perceptualtraining using game-based
principles, where an individualis rewarded for listening to
other sounds and is not rewardedfor listening to sounds like
their tinnitus, can be effective.
(23:20):
Because this is a way that wewould normally learn in our
day-to-day environments.
When we interact with things,something's positive, we do it
more, we get better at it.
If we don't do something, webecome poorer at it, and that's
the case with tinnitus.
Dr. Douglas L. Beck (23:36):
Yeah, and when I think about all of the
different studies that come tomind, you know, when I think
about fractal tones brilliantstuff, you know, from 20, 30
years ago and it's trying tomake you passively pay attention
to the fractal tones, which arepretty little sounds that your
brain pretty much can ignore, ifyou can get by with that.
And the theory, I guess, is thata fractal tongue is a more
(23:57):
pleasant thing to focus on.
If you're focusing on anything,focus on that.
And then you have, as youmentioned, masking, and
sometimes we used in years past,and some people probably still
do, white noise, broadband noise, narrowband noise.
But the other side of that isyou can use sounds like a
babbling brook or a rainforestagain to just give you something
(24:17):
else to attend to, and thatcould be a matter of distracting
the patient away from theirtinnitus or reorienting them to
another sound or covering uptheir tinnitus with another
sound.
So this is very cool that youspent the time and the energy to
get involved with attention,because I think it's always a
presumed player in tinnitus.
But we don't have a lot offactual, objective data here and
(24:40):
I think you're opening up thefloodgates.
I think this is going to starta whole new thought process on
how we manage tinnitus.
Dr. Grant Searchfield (24:48):
Well, thanks for that.
I guess you know ourunderstanding of tinnitus
obviously is growing, but Ithink that when we look at
therapies, often we think ofthem from a particular
philosophical perspective andusually they're more complex
than actually we trulyunderstand at different levels
(25:12):
of the hearing system.
And being able to manipulatethat For example, you could have
the babbling brook type ofsound on, you could have that on
and actually be tasked withlistening to it, and just those
two differences may enactdifferent neural processes and
change tinnitus in differentways.
(25:33):
So really, I think you knowmoving forward, the secrets for
success in tinnitus is beingable to use multiple
methodologies and then modifyingthose for an individual based
on what we understand.
As we understand more and more,both about the individual and
mechanisms, then we can tunethis even greater and the
(25:55):
combination of differenttherapies is more likely to be
beneficial than a single therapyapproach itself.
Where you're using masking oryou're using bimodal therapy or
you're using cognitivebehavioral therapy, each of
those may be beneficial on theirown, particularly for some
(26:16):
individuals, but being able toblend them in the right dose for
an individual so you get themost of everything is really
going to be something, I think,to keep our eyes on in the next
10 years.
Dr. Douglas L. Beck (26:30):
One of the things you said in passing is
the difference between passivelyattending or actively attending
.
I am a musician and I can tellyou that when I'm listening to
new music and I have myheadphones on and I'm super
interested to hear a bass lineor a lead guitar line, I don't
hear my tinnitus at all.
But when I'm figuring out thatthing, if I am totally focused
(26:51):
on my guitar work or my keyboardwork, I don't hear any tinnitus
.
Sometimes, when I have musicplaying in the background, I
hear my tinnitus and I thinkthat that reflects very well the
active versus passive attentionthat you're talking about here.
Blaise M. Delfino, M.S. - (27:05):
Also you know when you think about.
Dr. Douglas L. Beck (27:07):
Sesame Street.
I'm sure you had that in NewZealand.
You know the reason that wassuch a great educational tool
was not because children watchedTV, that wasn't it.
It was because they wereactively involved.
They'd march around the roomsaying the alphabet or saying
their numbers, and beingactively involved with TV, that
became a benefit.
Passively watching TV doesn'thelp you at all.
Nobody ever learned how to playfootball by passively watching
(27:30):
somebody else play football.
You have to get in there and doit right, and I think that
that's a big part of tinnitusmanagement is how active can you
get the person involved withtheir treatment?
If they're actively involvedwith their treatment, it's much
more likely to be successfulthan if they're just doing it
because they were told to do it.
Dr. Grant Searchfiel (27:47):
Absolutely , and part of that also is
understanding the therapy sothat they can believe in the
therapy right?
So a person that's coming intothis, who has doubts about the
therapy because they don't thinkit necessarily has the science
behind it, they're automaticallygoing to come in to this and
their motivation for undertakingit.
(28:08):
They're going to be a skeptic,so they are less likely to
actually engage.
So throughout this process, wehave to have the scientific
evidence to back this up.
And one of the important thingsI think to again reinforce is
when we are talking aboutattention.
It seems a very soft term, apsychological term, right,
(28:30):
something that you would putinto conversation, something
that you would put intoconversation, but it's
incredibly complex and it doesinvolve changes in the way that
the brain connects with otherparts of the brain the hearing
system and other parts of thebrain within the auditory system
, the strength of relationshipbetween neurons, the nerve cells
(28:50):
, the amount of chemicals thatare involved.
All of this is actuallyhappening.
So when we're talking aboutattention, it's actually a huge
field and it's fascinating, andeach of these different elements
can have a role to play intinnitus management and we
really are just scratching thesurface to begin to understand
(29:13):
how to apply this knowledge.
Dr. Douglas L. Beck (29:15):
I think you're right and I do believe
this is.
You just opened the floodgateson this.
Dr Serschfeld, thank you onceagain for joining us on the
Hearing Matters podcast.
I will look forward tohopefully catching up with you
in New Orleans at the AAAmeeting and, other than that, I
wish you a safe flight and enjoythis week.
Dr. Grant Searchfield (29:31):
Great Thanks to you, Doug, and all
your listeners.
Hopefully they'll find itinteresting.
Thank you to our partners.
Sycle, built for the entirehearing care practice.
Redux, the best dryer, handsdown.
Caption call by Sorenson, Lifeis calling.
CareCredit, here today to helpmore people hear tomorrow.
Fader Plugs, the world's firstcustom adjustable earplug.
(00:41):
Welcome back to another episodeof the Hearing Matters Podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Dr. Douglas L. Beck (00:56):
Good afternoon.
Welcome to the Hearing MattersPodcast.
This is Dr Doug Wasbeck, andtoday I'm interviewing an old
friend of mine, dr GrantZurchfeld, and he has a new
paper on the scoping review ofthe role of attention in
tinnitus management, and I foundthat article to be fascinating
and encompassing of so manythings.
So, grant, first of all, thanksfor being here today.
Dr. Grant Searchfield (01:16):
Yeah, pleasure to be here, Doug, and
always great to chat with you.
Dr. Douglas L. Beck (01:19):
And since you're in New Zealand, I should
say thanks for being heretomorrow, because we're day
ahead of us.
Dr. Grant Searchfield (01:24):
A bit of time traveling Doesn't hurt.
Dr. Douglas L. Beck (01:28):
Give me the essence of the paper, the
scoping review on the role ofattention, and then I want to
compare that to a few other moretypical analysis and treatment
modes for tinnitus.
Dr. Grant Searchfield (01:40):
The purpose for setting out to do
this is we've been working inthe space of attention and
tinnitus from a point of view oflooking at how it affects
severity, but also dating backto 2007, looking at therapies
that might harness attention totry and change the brain, and so
it was timely for us to have alook at the overall literature
(02:03):
and find out what was going on,and so we did a search of a
number of different databases,looking primarily at the role of
attention in therapy, asopposed to the role of attention
in tinnitus generally.
So our search terms weretinnitus, therapy, treatment and
(02:24):
attention.
Terms were tinnitus, therapy,treatment and attention, and the
goal was to try and identifythe place, the role that
attention had in differenttreatments, how it was being
measured, the strength of theresearch, where the gaps were.
So that could help drive usforward as well in our own
endeavors.
Dr. Douglas L. Beck (02:42):
Yeah, and when I'm looking through the
literature, we don't generallypay a lot of attention to
attention, right?
I mean we're presuming we haveattention when we're engaged in
tinnitus retraining therapy orif we look at progressive
tinnitus management, but wedon't speak specifically about
attention and what you've donehere.
(03:02):
Very interesting.
You say difficulties withattention are commonly reported
by people with tinnitus andattention contributes to
tinnitus' salience andsubsequent disability.
So tell, me about that.
Dr. Grant Searchfield (03:17):
Yeah, well, I think, simply, most
people recognize that if you payattention to something, it
becomes worse.
So that's fairly obvious.
And I think people might saywell, you know, this is
searching something thatactually you know, everybody
knows.
But tension is complicated andit's not necessarily a process
(03:42):
that we have to apply thought to.
Some of this is automatic.
Some of it involves the signalbeing important, unimportant how
the brain reacts to these sortsof things.
So when we talk about salience,what we mean is it is an
important signal.
Is it there that the brainshould attend to it?
And when we talk about survivaltype of mechanisms, we all want
(04:05):
to be aware of threateningsounds in our environment and
hearing is our survival sense.
Right, we can hear aroundcorners, we're aware of sound
24-7.
So our hearing system iscontinually on alert, but it
can't listen to everything and alot of its processing has to be
(04:26):
automatic and filter outdifferent things.
But in the case of tinnitus,when that starts, the brain has
great difficulty letting it goand it does draw attention, both
attention that is under ourcontrol to a certain degree, but
also attention that's automaticand driven by these survival
(04:48):
type of mechanisms.
So the need was really toexplore that, because you're
quite right, we take it somewhatfor granted that attention has
a role here, and even some ofthe articles that we reviewed
mentioned attention, but theydon't actually measure it, and
(05:09):
so we really wanted to say, okay, people are saying that
attention is important fortinnitus therapy.
How and does it change withtherapy?
Because if it did well, that'sobviously an important indicator
for something you should focuson.
If it didn't, something else ishappening.
So we looked at the literature.
(05:31):
Overwhelmingly there wasn't alot of great detail.
As you said, some of thebiggest studies that were
undertaken, ostensibly lookingat attention, didn't have very
good measures of attention, butthen others were reasonably
comprehensive, using behavioralmeasures, questionnaires, but
(05:53):
also objective measures that arerelated to measuring attention
using MRI and EEG and the like.
Dr. Douglas L. Beck (06:02):
And when I read your paper I noticed that
you did a number of things andyou reported on Stroop effects
and you reported on what happensto the attention level when
somebody is working on a puzzleor a difficult challenge.
Dr Sertfeld, in your work youactually did the Tower of Hanoi
study, which is more of a totalmind involvement and you have to
(06:24):
be attending to it very, verycarefully, like a Stroop test or
like the game Jenga.
You have to totally focus ifyou're going to succeed.
So tell me about that.
What did you do?
Dr. Grant Searchfield (06:34):
Yeah, well, in this case, Doug, we
were reviewing some work byTinnit Sanchez, actually in
Brazil, who had done thisparticular piece of work in
Brazil.
Who had done this particularpiece of work?
And it's really a variation onthe very famous Haller and
Bergman experiment from the1950s.
Haller and Bergman researchedwhat people would experience if
(06:57):
they went into a soundproof room.
You know they said come intothis room.
And then they asked peoplewhether they heard sounds.
Now, most people heard soundthat wasn't there and they
reported sounds very much liketinnitus.
In their study, people wereunoccupied, people engaging in a
(07:22):
task modified their awarenessof these internal sounds when
they were in that quietenvironment and what it found
was that if you were unoccupied,your attention was lingering
around you're more likely tohear the tinnitus.
If you're engaged in a physicalactivity you know, busy,
(07:44):
solving a puzzle then you areless likely to report it.
Busy work lives who haveretired recently and they're
less occupied, but they suddenlyreport tinnitus.
(08:10):
You question them.
You say, well, how long haveyou had tinnitus?
I've had it for a long time,but it's really now that it's
been a problem.
And you explore that a littlebit, they say, well, when I'm
busy doing something, it's notso much of a problem.
They say, well, when I'm busydoing something, you know, it's
not so much of a problem.
And that comes back again tothat perhaps obvious aspect of
tinnitus and attention.
(08:31):
But the less obvious aspect ofit is whether we can train that
so people don't have to beactively engaged, whether the
brain can let go of tinnitus,reset itself, adapt and not
focus on the tinnitusautomatically.
Now some of that isn't undertop-down brain control, it's
(08:53):
more basically this primitiveletting the sound through
because it's important.
So each level of the brain thatapplies a different sort of
processing to the signal isreally important there.
And really what we'reinterested in is there are all
sorts of ways of applyingtreatments, as everybody knows.
When they are applied withattention as a measure of change
(09:19):
, how effective are they inchanging attention?
And also, did a change inattention relate to a change in
tinnitus?
A little bit of a chicken andegg scenario.
We can't show one causes theother, but we're really
interested If tinnitus improveddid attention vis-a-vis?
(09:41):
And a number of studies showedthat.
Some studies quite convincingly, others less so.
Dr. Douglas L. Beck (09:49):
And when you talk about these other
studies, you're talking aboutsome fMRI studies, some EEG
studies, transcranial magneticstimulation, all these things
right.
Dr. Grant Searchfield (09:57):
Yeah, so we looked at, we broke it down
to the particular study type.
Many of the studies usedbehavioral measures.
You mentioned the Stroop test,which is the one where you see a
color and it's got the speltword which may or may not agree
with the color, and the brainhas to take time to process that
(10:20):
.
So tests like that and otherswhere we're looking at changes
in the brain, particularly partsof the brain that are typically
associated with attention, andthe best studies of course
combine both, because that'sreally really powerful.
One of the downsides of, ofcourse, having all these tests
(10:41):
is it's difficult to do largestudies right.
So when we looked at theliterature, the largest studies
were generally in the space ofpsychological interventions,
particularly perhaps cognitivebehavioral therapy.
They had large numbers ofparticipants but they very
rarely did any objective measure, so they were very seldom.
(11:04):
Did you see any measure of MRI,eeg or other objective measure,
whereas tasks that perhaps hadfewer participants but were more
focused on attention, soundtherapy and perceptual training,
they often combined a measureof attention, a behavioral
(11:28):
measure, a measure of tinnitusand perhaps either MRI or EEG.
Dr. Douglas L. Beck (11:36):
Music therapy in particular.
Dr. Grant Searchfield (11:37):
Well, yeah, now music therapy is an
interesting one here.
So music therapy also wasinvestigated quite a bit with
regards to the depth ofinformation.
Investigated quite a bit withregards to the depth of
information.
Now again for the listeners.
When we talk about musictherapy in this context, it's
(12:00):
not just about listening tomusic, because music therapy is
almost more of a psychologicaltherapy than a typical sound
therapy for tinnitus, becauseit's about engaging in the
production of the sound andunder the guidance of a
therapist.
So that certainly was one thatpulled out as slightly separate
(12:21):
from these other broadcategories as investigating
attention.
So the areas where there was astrength of information on
attention were sound-based andperceptual training therapies.
They did tend to have smallernumbers of participants.
Studies that suggested thatattention was playing a big role
(12:46):
often had larger number ofparticipants but fewer
investigations and obviouslythere's a trade-off here in
these sorts of studies lookingat what you can do with a
certain number of resources.
But, yeah, quite fascinating.
And you know we started outlooking at I was around about
(13:06):
500 articles that we surveyedthat had tinnitus attention in
therapy you know as key things.
Dr. Douglas L. Beck (13:13):
That's a lot of studies.
Dr. Grant Searchfield (13:14):
Yeah, but then we narrowed it down and we
ended up with less than 40 thatreally investigated that in any
detail.
So it shows you perhaps theassumptions that attention is
important, but there hasn't beena huge amount of research
undertaken on it.
Dr. Douglas L. Beck (13:32):
But you know, this is fascinating in so
many respects because you couldsay how this relates.
Well, I'll ask your opinion.
So how does attention relate to, let's say, trt and then let's
talk about PTF?
Do you see a difference betweenthose two with regard to
attention?
Dr. Grant Searchfield (13:48):
Well, I think that almost all therapies
would assign some role forattention.
When it comes to thenitty-gritty on how that
attention is changed, forexample.
That's where the differencesare whether you're operating on
a psychological level, alearning level or a sensory
(14:11):
level, and probably you knowit's actually the combination of
these things which is thereally the secret, secret recipe
.
So we know, for example, withtinnitus retraining therapy, the
idea is that we need tohabituate, both in terms of our
reactions, so we need to notreact as strongly to the
(14:31):
tinnitus as what we would whenwe find an annoying problem.
And clearly attention has arole there.
And, to a smaller degree, alsothe habituation of perception.
And this is where attention canhave quite a nuanced role in
modifying that, in changing thatand what that actually means
(14:55):
and how the brain actuallyadapts to focus.
And we think of attention assomething that's sort of on the
psychological domain.
And you know we controlattention.
We can attend to it, we cannot.
You know we attend to a soundthat's threatening, like the
sound of an ambulance siren.
You know we automatically reactto that, while we don't to
(15:17):
something quite benign, like thesound of our car engine or the
wheels on the road yeah, this isan important point that you
bring up in the paper is thatyou have to learn what to attend
to.
Dr. Douglas L. Beck (15:31):
We generally attend to human speech
and we uh, you know we have inthe states we call it hvac
heating, ventilation, airconditioning systems.
Right, so if you use that, or arefrigerator, or a 60 cycle,
you know, or an incandescentbulb, those make sounds but we
tune them out and that's, that'sbased on learning.
You know that they are noninjurious or non dangerous, non
(15:52):
threatening sounds, so you tunethem out and you pay no
attention.
And this, this point, I think,is so important in tinnitus
management because we areactually it's a little bit you
know, maladaptive.
We're focusing on a sound that'sprobably always there, more or
less, but we are attending to it, which, as you said earlier,
once we focus on it, we attendto it, we tend to perceive it
(16:15):
more dominantly.
Dr. Grant Searchfield (16:17):
Yeah, absolutely, and this is a very
well-entrenched system.
It's our mechanism that we goabout surviving our world.
We need to make decisions onwhat to attend to and what not
to attend to, because we can't Ican't attend to everything when
tinnitus comes on because it'sunusual, we haven't necessarily
(16:37):
experienced it.
We can't link it to somethingin our environment, naturally,
without our own focusedattention on it, innate
attention, just what ishappening for our survival means
that we become aware of it.
Now, if we are an anxiousperson, we might attend to it
(16:57):
even more, but even if we aren't, something that's annoying and
threatening in our environment,it's important for us to attend
to that.
So you mentioned, for example,the way that we learn.
So you know, naturally ourhearing system learns from our
experiences.
(17:18):
You know, when we're in ourmother's arms, when we're
crawling along the floor, whenwe're falling over things, when
we're interacting with things aswe grow up, when we begin to
listen to music, all thesethings we're learning and the
brain is changing.
So you know, it's important tounderstand, you know this
concept of neuroplasticity andlearning.
(17:39):
And so when we are learning,the brain is adapting, it's
organizing itself into anefficient manner, as is possible
, into an efficient manner as ispossible.
So when there is a change tothat, we have this tension, but
(17:59):
there's this change inplasticity as well and the brain
modifies itself in order to beable to hear and react
appropriately.
So you mentioned the sound of alight, an incandescent light,
for example.
Now, if we'd learnt, we'd grownup, that that sound was a
warning signal, we wouldn't beable just to sit there and say,
oh, that's just a light, youknow, I'm fine.
(18:20):
We just wouldn't be able to.
Our bodies wouldn't allow us todo that.
So that reaction, thatautomatic reaction to a sound,
that Might seem quite benign ifI say it to you, but actually
because it's internal, it'sconsistent, it's ongoing, you
can't escape it, it takes onunusual importance.
(18:43):
Now, the good thing, if there isa good thing, is the fact that
this plasticity can, of course,change.
It can be reversed or modified.
Course change.
It can be reversed or modified.
So just as we can become betterat hearing tinnitus, we can
(19:09):
also become poorer at hearing it.
But in order for that to happen, a lot of these mechanisms that
the brain automatically puts inplay from a survival type of
perspective has to be adjusted,and this is not under
necessarily willpower, so youcan't necessarily say I'm not
going to attend to this Right.
There are innate mechanismsthat we need to be able to
(19:31):
modify in there.
Some people are able to do thatbetter than others.
Some people need assistance inthat.
Dr. Douglas L. Beck (19:38):
Dr Sertsch, tell me about bimodal
stimulation.
When you have stimulation onthe tongue and auditory
stimulation, how does that workand fit in with the tension?
Dr. Grant Searchfield (19:47):
Well, I guess what we have to say is
that bimodal stimulation, bydefinition, is the combination
of more than one form ofstimulation and at the moment
there is one particular productavailable quite widely in the
United States that uses tonguestimulation and sound
stimulation.
There are other experimentalmodes that use neck stimulation
(20:11):
and sound stimulation, or soundstimulation, visual stimulation.
So these are all bimodaltherapies and they each have a
different mechanism that they'retrying to promote.
Generally, what we're saying is, if you're using multiple modes
, you're building on getting thebenefit of using two methods,
(20:33):
so two is better than one, threemight be better than one and
that they can be used toreinforce the primary mode of
stimulation.
The goal and the physiologythat's trying to be changed
there will depend both on soundthat's used, if sound is used,
but also the form of stimulation.
(20:55):
And it's a little bit uncertainhow these are modifying the
brain, because often there isn'tthe objective evidence to show
that the behavioral changes,what's causing those.
But essentially, what you'retrying to do is you're trying to
promote change within onesystem with stimulation of
another.
So you're answering to do isyou're trying to promote change
(21:16):
within one system withstimulation of another, so
you're answering to the secondone.
Dr. Douglas L. Beck (21:20):
Yeah, it's an attention-based mechanism
that is helping to relievetinnitus.
Dr. Grant Searchfield (21:25):
Yeah, so, for example, we know.
An example that's easier toperhaps understand is when we
use vision and hearing right.
Often we use hearing to gainour attention, but the vision
reinforces or helps to navigateour word and confirms what we're
(21:49):
actually hearing.
In the case of vision and in thecase of vision, sometimes it
will dominate the hearing.
So if there's a strong visualimage that contradicts the
hearing, sometimes that willplay.
So our senses will work in alltogether.
And when there's anincongruence between the two,
(22:11):
such as tinnitus, where there'ssound without vision of a
sound-making thing, this iswhere our sensory system can
particularly come out of whack.
So what we can see in thedifferent therapy types is
there's different ways that youcan affect attention.
Right, we can affect attentionto tinnitus by making the
(22:34):
tinnitus not audible.
So by masking all right ormasking another sound there may
draw attention away from thetinnitus.
So that's a passive process.
But we can also use training,where the person is actively
instructed and engaging in notlistening to the tinnitus and is
(22:58):
rewarded for not listening totinnitus and is if they do hear
to tinnitus, they're notrewarded for it.
And this sort of perceptualtraining using game-based
principles, where an individualis rewarded for listening to
other sounds and is not rewardedfor listening to sounds like
their tinnitus, can be effective.
(23:20):
Because this is a way that wewould normally learn in our
day-to-day environments.
When we interact with things,something's positive, we do it
more, we get better at it.
If we don't do something, webecome poorer at it, and that's
the case with tinnitus.
Dr. Douglas L. Beck (23:36):
Yeah, and when I think about all of the
different studies that come tomind, you know, when I think
about fractal tones brilliantstuff, you know, from 20, 30
years ago and it's trying tomake you passively pay attention
to the fractal tones, which arepretty little sounds that your
brain pretty much can ignore, ifyou can get by with that.
And the theory, I guess, is thata fractal tongue is a more
(23:57):
pleasant thing to focus on.
If you're focusing on anything,focus on that.
And then you have, as youmentioned, masking, and
sometimes we used in years past,and some people probably still
do, white noise, broadband noise, narrowband noise.
But the other side of that isyou can use sounds like a
babbling brook or a rainforestagain to just give you something
(24:17):
else to attend to, and thatcould be a matter of distracting
the patient away from theirtinnitus or reorienting them to
another sound or covering uptheir tinnitus with another
sound.
So this is very cool that youspent the time and the energy to
get involved with attention,because I think it's always a
presumed player in tinnitus.
But we don't have a lot offactual, objective data here and
(24:40):
I think you're opening up thefloodgates.
I think this is going to starta whole new thought process on
how we manage tinnitus.
Dr. Grant Searchfield (24:48):
Well, thanks for that.
I guess you know ourunderstanding of tinnitus
obviously is growing, but Ithink that when we look at
therapies, often we think ofthem from a particular
philosophical perspective andusually they're more complex
than actually we trulyunderstand at different levels
(25:12):
of the hearing system.
And being able to manipulatethat For example, you could have
the babbling brook type ofsound on, you could have that on
and actually be tasked withlistening to it, and just those
two differences may enactdifferent neural processes and
change tinnitus in differentways.
(25:33):
So really, I think you knowmoving forward, the secrets for
success in tinnitus is beingable to use multiple
methodologies and then modifyingthose for an individual based
on what we understand.
As we understand more and more,both about the individual and
mechanisms, then we can tunethis even greater and the
(25:55):
combination of differenttherapies is more likely to be
beneficial than a single therapyapproach itself.
Where you're using masking oryou're using bimodal therapy or
you're using cognitivebehavioral therapy, each of
those may be beneficial on theirown, particularly for some
(26:16):
individuals, but being able toblend them in the right dose for
an individual so you get themost of everything is really
going to be something, I think,to keep our eyes on in the next
10 years.
Dr. Douglas L. Beck (26:30):
One of the things you said in passing is
the difference between passivelyattending or actively attending
.
I am a musician and I can tellyou that when I'm listening to
new music and I have myheadphones on and I'm super
interested to hear a bass lineor a lead guitar line, I don't
hear my tinnitus at all.
But when I'm figuring out thatthing, if I am totally focused
(26:51):
on my guitar work or my keyboardwork, I don't hear any tinnitus
.
Sometimes, when I have musicplaying in the background, I
hear my tinnitus and I thinkthat that reflects very well the
active versus passive attentionthat you're talking about here.
Blaise M. Delfino, M.S. - (27:05):
Also you know when you think about.
Dr. Douglas L. Beck (27:07):
Sesame Street.
I'm sure you had that in NewZealand.
You know the reason that wassuch a great educational tool
was not because children watchedTV, that wasn't it.
It was because they wereactively involved.
They'd march around the roomsaying the alphabet or saying
their numbers, and beingactively involved with TV, that
became a benefit.
Passively watching TV doesn'thelp you at all.
Nobody ever learned how to playfootball by passively watching
(27:30):
somebody else play football.
You have to get in there and doit right, and I think that
that's a big part of tinnitusmanagement is how active can you
get the person involved withtheir treatment?
If they're actively involvedwith their treatment, it's much
more likely to be successfulthan if they're just doing it
because they were told to do it.
Dr. Grant Searchfiel (27:47):
Absolutely , and part of that also is
understanding the therapy sothat they can believe in the
therapy right?
So a person that's coming intothis, who has doubts about the
therapy because they don't thinkit necessarily has the science
behind it, they're automaticallygoing to come in to this and
their motivation for undertakingit.
(28:08):
They're going to be a skeptic,so they are less likely to
actually engage.
So throughout this process, wehave to have the scientific
evidence to back this up.
And one of the important thingsI think to again reinforce is
when we are talking aboutattention.
It seems a very soft term, apsychological term, right,
(28:30):
something that you would putinto conversation, something
that you would put intoconversation, but it's
incredibly complex and it doesinvolve changes in the way that
the brain connects with otherparts of the brain the hearing
system and other parts of thebrain within the auditory system
, the strength of relationshipbetween neurons, the nerve cells
(28:50):
, the amount of chemicals thatare involved.
All of this is actuallyhappening.
So when we're talking aboutattention, it's actually a huge
field and it's fascinating, andeach of these different elements
can have a role to play intinnitus management and we
really are just scratching thesurface to begin to understand
(29:13):
how to apply this knowledge.
Dr. Douglas L. Beck (29:15):
I think you're right and I do believe
this is.
You just opened the floodgateson this.
Dr Serschfeld, thank you onceagain for joining us on the
Hearing Matters podcast.
I will look forward tohopefully catching up with you
in New Orleans at the AAAmeeting and, other than that, I
wish you a safe flight and enjoythis week.
Dr. Grant Searchfield (29:31):
Great Thanks to you, Doug, and all
your listeners.
Hopefully they'll find itinteresting.
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