A conceptual cognitive model proposed by McKenna et al. (2014), incorporates a cognitive model of distress to explain tinnitus-associated insomnia (Harvey 2002). McKenna et al. argue that the tinnitus-signal distress and bodily arousal are provoked mainly through negative cognitive misinterpretations, leading to inaccurate evaluations of sensory activity and distorted perceptions (see Fig. 8.2). It is proposed that the resulting stress and hypervigilance contribute to a feedback cycle that exacerbates the distress associated with flawed sensory processing, of which tinnitus may be a major component. The model attributes a fundamental role to the negative evaluation of tinnitus. The negative evaluation of the tinnitus percept can be viewed as comprised of primary and secondary appraisals. For example, a person might initially appraise the tinnitus as being threatening to their health and then make a secondary appraisal of their (in)ability to cope with it.

Clinical trials in which this model is applied to treatment, by which the clinical relevance of the model can be tested, have not taken place yet. However, evidence exists that cognitive processes, such as interpretation, attention, and memory, are indeed involved in chronic tinnitus suffering (Andersson et al. 2013; Conrad et al. 2011; Rossiter et al. 2006; Stevens et al. 2007), though these studies were not specifically aimed at validating the model.

Several so-called “cognitive behavioral” accounts for tinnitus have been postulated (Cima et al. 2011a; Hallam et al. 1984; Kleinstauber et al. 2012; McKenna et al. 2014). A promising one is based on a fear-avoidance model (FA model) of chronic pain (Vlaeyen and Linton 2000, 2012), since in this model, predictions about the behavioral components in the maintenance of tinnitus distress are included. The FA model (Fig. 8.3) for chronic tinnitus offers explanatory predictions about both the cognitive processes and the behavioral mechanisms. It predicts that individuals perceiving the tinnitus signal are subject to automatic emotional and sympathetic responses. These symptoms are misinterpreted as harmful or threatening. If the signal persists, the coinciding threatening (alarm) states, which indicate malignance of the signal, elicit conditioned, both classical and operant, fear responses, i.e., fear, increased attention, and safety seeking, i.e., avoidance and escape behaviors. These safety behaviors become negatively reinforced through instant decreased fear, which is adaptive in the acute phase. In other words, by avoiding, or not exposing themselves to tinnitus-related perceptions, patients learn that their fear instantly diminishes. However, in the long run, through persistent avoidance of tinnitus percept as well as tinnitus-eliciting or tinnitus-increasing stimuli, the heightened fear and fear responses, such as hypervigilance and safety seeking, are maintained. Avoidance behaviors subsequently lead to task interference and functional disability (Blaesing and Kroener-Herwig 2012; Hesser et al. 2009). The maintained high threat value of the tinnitus leads to increased tinnitus severity and distress, feeding into an endless circle of increased disability (Cima et al. 2011b).

A typical feature of the FA model is its prediction; next to the maladaptive pathway (leftward), an alternative and more adaptive pathway (turning right) is proposed, whereby a positive or neutral evaluation of the tinnitus results in no or low fear of the tinnitus and in partially or completely decreased distress. In other words, the tinnitus sound is accepted by the system as being benign; therefore, no unwanted attentional resources are needed. In turn, avoidance and/or escape behaviors do not interfere with daily tasks, resulting in lack of severe disability due to tinnitus.

Accumulating evidence indicates that a cognitive behavioral treatment, based on this fear-avoidance notion, which targets reappraisal of and exposure to the tinnitus sound, significantly reduces tinnitus distress as well as tinnitus suffering and improves the quality of life and daily functioning of tinnitus patients (Andersson 2002; Andersson and Lyttkens 1999; Andersson et al. 2002; Cima et al. 2012; H. Hesser et al. 2011; Hoare et al. 2011; Martinez-Devesa et al. 2010). However, the cause-effect relationships of specific learning mechanisms are still unknown (Cima et al. 2011a; J. A. Henry et al. 2005a; Kleinstauber et al. 2012).

In overview, consensus among the theoretical models exists regarding the evidence that a neutral acoustic signal receives negative valence by means of classical conditioning, in which an individual learns that the signal becomes predictive for negative states (“false alarms”) as a result of automatic negative responses elicited by this signal (Pawel J. Jastreboff and Jastreboff 2006; Vlaeyen and Linton 2000). Both cognitive models highlight the importance of cognitive processes, and although behavioral consequences are mentioned and recognized as important, they are considered secondary for the maintenance and therefore also for the treatment of chronic tinnitus suffering. Conscious cognitive processes are emphasized, as these constitute the main therapeutic targets in treatments stemming from these models, hypothesizing that the classical (involuntary) learning mechanisms are of lesser importance.

Following the lines of theoretical reasoning, it can be postulated that conditioned negative responses are the main cause of the suffering (Jastreboff and Jastreboff 2006) and that these aversive responses toward the tinnitus sound lead to misinterpretations feeding back into negative evaluations and fear responses (Hallam et al. 1988; Hallam et al. 1984; P. J. Jastreboff 2007; McKenna et al. 2014). Building on these principles, the FA model offers predictions about fearful responses (emotional and attentional) and behaviors (Cima et al. 2011a), which explain the maintained tinnitus distress. This latter premise is based on an operant component in learning theory terms and remains unexplained, though mentioned, both in the neurophysiological model as well as the cognitive model. The FA model provides specific predictions on this level, which leads us to the main difference between the models.

While the NP model deals mainly with tinnitus generation and detection and the habituation and cognitive models emphasize the voluntary conscious processing of the tinnitus, the FA model is predictive beyond that and picks up there where the other models stop being explanatory. The main conceptual overlap might lie at the level of the detection/perception and interpretation level, and the classical learning principles are involved purportedly, as was described above. The models differ in explaining how these learning principles—both classical and specifically the operant learning mechanisms—may play a role. The NP model is mainly based on neurophysiological processes and attempts to explain the psychological path in neurophysiological terms. This provides only general descriptions of classical and operant conditioning mechanisms. The habituation and cognitive models both state that the conscious alteration of negative interpretations will decrease arousal and distress as a result of tinnitus, with less emphasis on the behavioral processes. As opposed to this, the FA model is based on associative learning and operant principles and offers explanatory predictions about the classical and the behavioral mechanisms. This fear-avoidance approach integrates previous concepts and might prove helpful in discovering new venues of investigations, as well as in offering means to determine why not only cognitive but also behavioral treatment approaches are repeatedly found to be successful (Tutorial 8.1).

Next to the theoretical frameworks, a short overview of developments within the cognitive behavioral therapies (CBT) during the past decades is necessary, to provide the background for the development of treatments for reducing tinnitus-related distress. To answer the question as to what is meant by the cognitive behavioral therapies, we will take a short journey in the past.

As it has been described in the previous sections of this chapter, distress is an aversive state, which is the result of the organism failing to adapt to stressors. Tinnitus-related distress, and the treatment thereof, hardly focusses on the tinnitus sound itself, since indeed emotional distress is the main and the most significant factor in predicting the variability in quality of life of tinnitus patients is psychological distress (Cima et al. 2011a, b; Erlandsson and Hallberg 2000). In individuals with persistent tinnitus, the acoustic characteristics of tinnitus percept (e.g., loudness or pitch) are hardly associated with tinnitus severity or treatment outcome (Jastreboff 1990; Jastreboff and Hazell 1993). The initial negative evaluation and subsequent fear responses leading to the overall distress might be more relevant in defining the severity of complaints than the tinnitus percept itself.

Accumulating evidence suggests that fear responses, cognitive misinterpretations, negative emotional reactivity, attentional processes, and misappropriated behavioral strategies are crucial in dysfunctional habituation leading to severe tinnitus-related distress (Andersson and McKenna 2006; Erlandsson and Hallberg 2000; Kroner-Herwig et al. 2003; Zachriat and Kroner-Herwig 2004). In other chronic disorders, like irritable bowel syndrome, chronic fatigue syndrome (Deary et al. 2007), and chronic pain disorder (Gatchel et al. 2007), psychological mechanisms, predicting or promoting dysfunctional responses to symptoms, have similarly shown to be significant predictors of suffering (Crombez et al. 1999; Rief and Broadbent 2007).