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What is tinnitus? 

Typical definitions of tinnitus talk about the derivation of the work from the Latin tinnire (to ring), and how it is the perception of a sound not present in the external environment. Whilst both of these are true, to some extent they miss the point: for people with troublesome tinnitus it is an intrusive, often complex sound experience, that can vary with mood, and sound environment, but also spontaneously and alarmingly. The ways in which tinnitus can affect a person are almost as varied as the number of people that are troubled with it, but common issues include poor sleep (both duration and quality), reduced concentration, and both emotional and physical distress. 

Why is tinnitus bothersome? 

This issue is both highly complex, but also simple and clear. There are research models of tinnitus that consider the links with emotion, cognition, and of the role of fear-avoidance (see here for a summary research paper https://link.springer.com/article/10.1007%2Fs00106-019-0633-7).  
However, the situation can be illustrated more simply. Based on the idea that human hearing seeks to identify and react to intrusive sound that is potentially a sign of danger, Figure 1 demonstrates how the awareness of tinnitus can trigger reactions that are emotional and physical, and how each of these reactions can feed off one another, leading to severe distress. 

The aim of tinnitus therapy is to reduce each of the aspects of troublesome tinnitus using targeted therapy.  

Aspect of tinnitus 
First stage approach 
Advanced approach 
Awareness of the tinnitus sound 
Modern hearing aids when needed 
Sound therapy to blend with the tinnitus signal 
Physical arousal 
Relaxation therapy 
Emotional distress 
Audiological counselling 
Psychological therapy 
Sleep problems 
Bedside sound therapy 
Basic sleep hygiene 
Psychological therapy 

What is hyperacusis? 

In normal circumstances, our hearing changes in sensitivity with how loud our sound environment is, and how we are feeling: so that we reduce the sensation of loud sounds, and sound can seem louder when we are anxious, afraid, or upset. In some people this system of changing control of loudness fails, so that all sound seems loud, all of the time, and this has been given the name hyperacusis (decreased sound tolerance). Additionally, for some people sound is painful as well as loud, and this can be especially burdensome. 

Why is hyperacusis bothersome? 

The experience of the world of sound becoming intense, distressing, or painful, can lead people to withdraw from work life, family life, socialising, and everyday tasks such as shopping and cleaning. Many people use hearing protection to prevent being exposed to sound. Both the withdrawal and the ear protection may initially be helpful, but can in fact cause the hyperacusis to persist, or even to worsen. 
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