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The Buzz Over Tuning Out Tinnitus feat. Dr. Grant Searchfield

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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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Blaise M. Delfino, M.S. - HIS:

Thank you to our partners. Sycle, built for the entire hearing care practice. Redux, the best dryer, hands down. Caption call by Sorenson, Life is calling. CareCredit, here today to help more people hear tomorrow. Fader Plugs, the world's first custom adjustable earplug. Welcome back to another episode of the Hearing Matters Podcast. I'm founder and host Blaise Delfino and, as a friendly reminder, this podcast is separate from my work at Starkey.

Dr. Douglas L. Beck:

Good afternoon. Welcome to the Hearing Matters Podcast. This is Dr Doug Wasbeck, and today I'm interviewing an old friend of mine, dr Grant Zurchfeld, and he has a new paper on the scoping review of the role of attention in tinnitus management, and I found that article to be fascinating and encompassing of so many things. So, grant, first of all, thanks for being here today.

Dr. Grant Searchfield:

Yeah, pleasure to be here, Doug, and always great to chat with you.

Dr. Douglas L. Beck:

And since you're in New Zealand, I should say thanks for being here tomorrow, because we're day ahead of us.

Dr. Grant Searchfield:

A bit of time traveling Doesn't hurt.

Dr. Douglas L. Beck:

Give me the essence of the paper, the scoping review on the role of attention, and then I want to compare that to a few other more typical analysis and treatment modes for tinnitus.

Dr. Grant Searchfield:

The purpose for setting out to do this is we've been working in the space of attention and tinnitus from a point of view of looking at how it affects severity, but also dating back to 2007, looking at therapies that might harness attention to try and change the brain, and so it was timely for us to have a look at the overall literature 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, as opposed to the role of attention in tinnitus generally. So our search terms were tinnitus, therapy, treatment and attention. Terms were tinnitus, therapy, treatment and attention, and the goal was to try and identify the place, the role that attention had in different treatments, how it was being measured, the strength of the research, where the gaps were. So that could help drive us forward as well in our own endeavors.

Dr. Douglas L. Beck:

Yeah, and when I'm looking through the literature, we don't generally pay a lot of attention to attention, right? I mean we're presuming we have attention when we're engaged in tinnitus retraining therapy or if we look at progressive tinnitus management, but we don't speak specifically about attention and what you've done here. Very interesting. You say difficulties with attention are commonly reported by people with tinnitus and attention contributes to tinnitus' salience and subsequent disability. So tell, me about that.

Dr. Grant Searchfield:

Yeah, well, I think, simply, most people recognize that if you pay attention to something, it becomes worse. So that's fairly obvious. And I think people might say well, you know, this is searching something that actually you know, everybody knows. But tension is complicated and it's not necessarily a process that we have to apply thought to. Some of this is automatic. Some of it involves the signal being important, unimportant how the brain reacts to these sorts of things. So when we talk about salience, what we mean is it is an important signal. Is it there that the brain should attend to it?

Dr. Grant Searchfield:

And when we talk about survival type of mechanisms, we all want to be aware of threatening sounds in our environment and hearing is our survival sense. Right, we can hear around corners, we're aware of sound 24-7. So our hearing system is continually on alert, but it can't listen to everything and a lot of its processing has to be automatic and filter out different things. But in the case of tinnitus, when that starts, the brain has great difficulty letting it go and it does draw attention, both attention that is under our control to a certain degree, but also attention that's automatic and driven by these survival type of mechanisms.

Dr. Grant Searchfield:

So the need was really to explore that, because you're quite right, we take it somewhat for granted that attention has a role here, and even some of the articles that we reviewed mentioned attention, but they don't actually measure it, and so we really wanted to say, okay, people are saying that attention is important for tinnitus therapy. How and does it change with therapy? Because if it did well, that's obviously an important indicator for something you should focus on. If it didn't, something else is happening. So we looked at the literature. Overwhelmingly there wasn't a lot of great detail. As you said, some of the biggest studies that were undertaken, ostensibly looking at attention, didn't have very good measures of attention, but then others were reasonably comprehensive, using behavioral measures, questionnaires, but also objective measures that are related to measuring attention using MRI and EEG and the like.

Dr. Douglas L. Beck:

And when I read your paper I noticed that you did a number of things and you reported on Stroop effects and you reported on what happens to the attention level when somebody is working on a puzzle or a difficult challenge. Dr Sertfeld, in your work you actually did the Tower of Hanoi study, which is more of a total mind involvement and you have to be attending to it very, very carefully, like a Stroop test or like the game Jenga. You have to totally focus if you're going to succeed. So tell me about that. What did you do?

Dr. Grant Searchfield:

Yeah, well, in this case, Doug, we were reviewing some work by Tinnit Sanchez, actually in Brazil, who had done this particular piece of work in Brazil. Who had done this particular piece of work? And it's really a variation on the very famous Haller and Bergman experiment from the 1950s. Haller and Bergman researched what people would experience if they went into a soundproof room. You know they said come into this room. And then they asked people whether they heard sounds. Now, most people heard sound that wasn't there and they reported sounds very much like tinnitus.

Dr. Grant Searchfield:

In their study, people were unoccupied, people engaging in a task modified their awareness of these internal sounds when they were in that quiet environment and what it found was that if you were unoccupied, your attention was lingering around you're more likely to hear the tinnitus. If you're engaged in a physical activity you know, busy, solving a puzzle then you are less likely to report it. Busy work lives who have retired recently and they're less occupied, but they suddenly report tinnitus. You question them. You say, well, how long have you 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 little bit, they say, well, when I'm busy doing something, it's not so much of a problem. They say, well, when I'm busy doing something, you know, it's not so much of a problem.

Dr. Grant Searchfield:

And that comes back again to that perhaps obvious aspect of tinnitus and attention. But the less obvious aspect of it is whether we can train that so people don't have to be actively engaged, whether the brain can let go of tinnitus, reset itself, adapt and not focus on the tinnitus automatically. Now some of that isn't under top-down brain control, it's more basically this primitive letting the sound through because it's important. So each level of the brain that applies a different sort of processing to the signal is really important there. And really what we're interested in is there are all sorts of ways of applying treatments, as everybody knows. When they are applied with attention as a measure of change, how effective are they in changing attention? And also, did a change in attention relate to a change in tinnitus? A little bit of a chicken and egg scenario. We can't show one causes the other, but we're really interested If tinnitus improved did attention vis-a-vis? And a number of studies showed that. Some studies quite convincingly, others less so.

Dr. Douglas L. Beck:

And when you talk about these other studies, you're talking about some fMRI studies, some EEG studies, transcranial magnetic stimulation, all these things right.

Dr. Grant Searchfield:

Yeah, so we looked at, we broke it down to the particular study type. Many of the studies used behavioral measures. You mentioned the Stroop test, which is the one where you see a color and it's got the spelt word which may or may not agree with the color, and the brain has to take time to process that. So tests like that and others where we're looking at changes in the brain, particularly parts of the brain that are typically associated with attention, and the best studies of course combine both, because that's really really powerful.

Dr. Grant Searchfield:

One of the downsides of, of course, having all these tests is it's difficult to do large studies right. So when we looked at the literature, the largest studies were generally in the space of psychological interventions, particularly perhaps cognitive behavioral therapy. They had large numbers of participants but they very rarely did any objective measure, so they were very seldom. Did you see any measure of MRI, eeg or other objective measure, whereas tasks that perhaps had fewer participants but were more focused on attention, sound therapy and perceptual training, they often combined a measure of attention, a behavioral measure, a measure of tinnitus and perhaps either MRI or EEG.

Dr. Douglas L. Beck:

Music therapy in particular.

Dr. Grant Searchfield:

Well, yeah, now music therapy is an interesting one here. So music therapy also was investigated quite a bit with regards to the depth of information. Investigated quite a bit with regards to the depth of information. Now again for the listeners. When we talk about music therapy in this context, it's not just about listening to music, because music therapy is almost more of a psychological therapy than a typical sound therapy for tinnitus, because it's about engaging in the production of the sound and under the guidance of a therapist.

Dr. Grant Searchfield:

So that certainly was one that pulled out as slightly separate from these other broad categories as investigating attention. So the areas where there was a strength of information on attention were sound-based and perceptual training therapies. They did tend to have smaller numbers of participants. Studies that suggested that attention was playing a big role often had larger number of participants but fewer investigations and obviously there's a trade-off here in these sorts of studies looking at what you can do with a certain number of resources. But, yeah, quite fascinating. And you know we started out looking at I was around about 500 articles that we surveyed that had tinnitus attention in therapy you know as key things.

Dr. Douglas L. Beck:

That's a lot of studies.

Dr. Grant Searchfield:

Yeah, but then we narrowed it down and we ended up with less than 40 that really investigated that in any detail. So it shows you perhaps the assumptions that attention is important, but there hasn't been a huge amount of research undertaken on it.

Dr. Douglas L. Beck:

But you know, this is fascinating in so many respects because you could say 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 between those two with regard to attention?

Dr. Grant Searchfield:

Well, I think that almost all therapies would assign some role for attention. When it comes to the nitty-gritty on how that attention is changed, for example. That's where the differences are whether you're operating on a psychological level, a learning level or a sensory level, and probably you know it's actually the combination of these things which is the really the secret, secret recipe. So we know, for example, with tinnitus retraining therapy, the idea is that we need to habituate, both in terms of our reactions, so we need to not react as strongly to the tinnitus as what we would when we find an annoying problem. And clearly attention has a role there. And, to a smaller degree, also the habituation of perception. And this is where attention can have quite a nuanced role in modifying that, in changing that and what that actually means and how the brain actually adapts to focus.

Dr. Grant Searchfield:

And we think of attention as something that's sort of on the psychological domain. And you know we control attention. We can attend to it, we cannot. You know we attend to a sound that's threatening, like the sound of an ambulance siren. You know we automatically react to that, while we don't to something quite benign, like the sound of our car engine or the wheels on the road yeah, this is an important point that you bring up in the paper is that you have to learn what to attend to.

Dr. Douglas L. Beck:

We generally attend to human speech and we uh, you know we have in the states we call it hvac heating, ventilation, air conditioning systems. Right, so if you use that, or a refrigerator, or a 60 cycle, you know, or an incandescent bulb, those make sounds but we tune them out and that's, that's based on learning. You know that they are non injurious or non dangerous, non threatening sounds, so you tune them out and you pay no attention. And this, this point, I think, is so important in tinnitus management because we are actually it's a little bit you know, maladaptive.

Dr. Douglas L. Beck:

We're focusing on a sound that's probably always there, more or less, but we are attending to it, which, as you said earlier, once we focus on it, we attend to it, we tend to perceive it more dominantly.

Dr. Grant Searchfield:

Yeah, absolutely, and this is a very well-entrenched system. It's our mechanism that we go about surviving our world. We need to make decisions on what to attend to and what not to attend to, because we can't I can't attend to everything when tinnitus comes on because it's unusual, we haven't necessarily experienced it. We can't link it to something in our environment, naturally, without our own focused attention on it, innate attention, just what is happening for our survival means that we become aware of it. Now, if we are an anxious person, we might attend to it 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 our hearing system learns from our experiences. You know, when we're in our mother's arms, when we're crawling along the floor, when we're falling over things, when we're interacting with things as we grow up, when we begin to listen to music, all these things we're learning and the brain is changing. So you know, it's important to understand, you know this concept of neuroplasticity and learning. And so when we are learning, the brain is adapting, it's organizing itself into an efficient manner, as is possible, into an efficient manner as is possible. So when there is a change to that, we have this tension, but there's this change in plasticity as well and the brain modifies itself in order to be able to hear and react appropriately.

Dr. Grant Searchfield:

So you mentioned the sound of a light, an incandescent light, for example. Now, if we'd learnt, we'd grown up, that that sound was a warning signal, we wouldn't be able just to sit there and say, oh, that's just a light, you know, I'm fine. We just wouldn't be able to. Our bodies wouldn't allow us to do that. So that reaction, that automatic reaction to a sound, that Might seem quite benign if I say it to you, but actually because it's internal, it's consistent, it's ongoing, you can't escape it, it takes on unusual importance.

Dr. Grant Searchfield:

Now, the good thing, if there is a 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 better at hearing tinnitus, we can also become poorer at hearing it. But in order for that to happen, a lot of these mechanisms that the brain automatically puts in play from a survival type of perspective has to be adjusted, and this is not under necessarily willpower, so you can't necessarily say I'm not going to attend to this Right. There are innate mechanisms that we need to be able to modify in there. Some people are able to do that better than others. Some people need assistance in that.

Dr. Douglas L. Beck:

Dr Sertsch, tell me about bimodal stimulation. When you have stimulation on the tongue and auditory stimulation, how does that work and fit in with the tension?

Dr. Grant Searchfield:

Well, I guess what we have to say is that bimodal stimulation, by definition, is the combination of more than one form of stimulation and at the moment there is one particular product available quite widely in the United States that uses tongue stimulation and sound stimulation. There are other experimental modes that use neck stimulation and sound stimulation, or sound stimulation, visual stimulation. So these are all bimodal therapies and they each have a different mechanism that they're trying to promote. Generally, what we're saying is, if you're using multiple modes, you're building on getting the benefit of using two methods, so two is better than one, three might be better than one and that they can be used to reinforce the primary mode of stimulation.

Dr. Grant Searchfield:

The goal and the physiology that's trying to be changed there will depend both on sound that's used, if sound is used, but also the form of stimulation. And it's a little bit uncertain how these are modifying the brain, because often there isn't the objective evidence to show that the behavioral changes, what's causing those. But essentially, what you're trying to do is you're trying to promote change within one system with stimulation of another. So you're answering to do is you're trying to promote change within one system with stimulation of another, so you're answering to the second one.

Dr. Douglas L. Beck:

Yeah, it's an attention-based mechanism that is helping to relieve tinnitus.

Dr. Grant Searchfield:

Yeah, so, for example, we know. An example that's easier to perhaps understand is when we use vision and hearing right. Often we use hearing to gain our attention, but the vision reinforces or helps to navigate our word and confirms what we're actually hearing.

Dr. Grant Searchfield:

In the case of vision and in the case of vision, sometimes it will dominate the hearing. So if there's a strong visual image that contradicts the hearing, sometimes that will play. So our senses will work in all together. And when there's an incongruence between the two, such as tinnitus, where there's sound without vision of a sound-making thing, this is where our sensory system can particularly come out of whack.

Dr. Grant Searchfield:

So what we can see in the different therapy types is there's different ways that you can affect attention. Right, we can affect attention to tinnitus by making the tinnitus not audible. So by masking all right or masking another sound there may draw attention away from the tinnitus. So that's a passive process. But we can also use training, where the person is actively instructed and engaging in not listening to the tinnitus and is rewarded for not listening to tinnitus and is if they do hear to tinnitus, they're not rewarded for it. And this sort of perceptual training using game-based principles, where an individual is rewarded for listening to other sounds and is not rewarded for listening to sounds like their tinnitus, can be effective. Because this is a way that we would 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, we become poorer at it, and that's the case with tinnitus.

Dr. Douglas L. Beck:

Yeah, and when I think about all of the different studies that come to mind, you know, when I think about fractal tones brilliant stuff, you know, from 20, 30 years ago and it's trying to make you passively pay attention to the fractal tones, which are pretty little sounds that your brain pretty much can ignore, if you can get by with that.

Dr. Douglas L. Beck:

And the theory, I guess, is that a fractal tongue is a more pleasant thing to focus on. If you're focusing on anything, focus on that. And then you have, as you mentioned, 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 is you can use sounds like a babbling brook or a rainforest again to just give you something else to attend to, and that could be a matter of distracting the patient away from their tinnitus or reorienting them to another sound or covering up their tinnitus with another sound. So this is very cool that you spent 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 of factual, objective data here and I think you're opening up the floodgates. I think this is going to start a whole new thought process on how we manage tinnitus.

Dr. Grant Searchfield:

Well, thanks for that.

Dr. Grant Searchfield:

I guess you know our understanding of tinnitus obviously is growing, but I think that when we look at therapies, often we think of them from a particular philosophical perspective and usually they're more complex than actually we truly understand at different levels of the hearing system.

Dr. Grant Searchfield:

And being able to manipulate that For example, you could have the babbling brook type of sound on, you could have that on and actually be tasked with listening to it, and just those two differences may enact different neural processes and change tinnitus in different ways. So really, I think you know moving forward, the secrets for success in tinnitus is being able to use multiple methodologies and then modifying those for an individual based on what we understand. As we understand more and more, both about the individual and mechanisms, then we can tune this even greater and the combination of different therapies is more likely to be beneficial than a single therapy approach itself. Where you're using masking or you're using bimodal therapy or you're using cognitive behavioral therapy, each of those may be beneficial on their own, particularly for some individuals, but being able to blend them in the right dose for an individual so you get the most of everything is really going to be something, I think, to keep our eyes on in the next 10 years.

Dr. Douglas L. Beck:

One of the things you said in passing is the difference between passively attending or actively attending. I am a musician and I can tell you that when I'm listening to new music and I have my headphones on and I'm super interested to hear a bass line or a lead guitar line, I don't hear my tinnitus at all. But when I'm figuring out that thing, if I am totally focused on my guitar work or my keyboard work, I don't hear any tinnitus. Sometimes, when I have music playing in the background, I hear my tinnitus and I think that that reflects very well the active versus passive attention that you're talking about here.

Blaise M. Delfino, M.S. - HIS:

Also you know when you think about.

Dr. Douglas L. Beck:

Sesame Street. I'm sure you had that in New Zealand. You know the reason that was such a great educational tool was not because children watched TV, that wasn't it. It was because they were actively involved. They'd march around the room saying the alphabet or saying their numbers, and being actively involved with TV, that became a benefit. Passively watching TV doesn't help you at all. Nobody ever learned how to play football by passively watching somebody else play football. You have to get in there and do it right, and I think that that's a big part of tinnitus management is how active can you get the person involved with their treatment? If they're actively involved with their treatment, it's much more likely to be successful than if they're just doing it because they were told to do it.

Dr. Grant Searchfield:

Absolutely, and part of that also is understanding the therapy so that they can believe in the therapy right?

Dr. Grant Searchfield:

So a person that's coming into this, who has doubts about the therapy because they don't think it necessarily has the science behind it, they're automatically going to come in to this and their motivation for undertaking it.

Dr. Grant Searchfield:

They're going to be a skeptic, so they are less likely to actually engage. So throughout this process, we have to have the scientific evidence to back this up. And one of the important things I think to again reinforce is when we are talking about attention. It seems a very soft term, a psychological term, right, something that you would put into conversation, something that you would put into conversation, but it's incredibly complex and it does involve changes in the way that the brain connects with other parts of the brain the hearing system and other parts of the brain within the auditory system, the strength of relationship between neurons, the nerve cells, the amount of chemicals that are involved. All of this is actually happening. So when we're talking about attention, it's actually a huge field and it's fascinating, and each of these different elements can have a role to play in tinnitus management and we really are just scratching the surface to begin to understand how to apply this knowledge.

Dr. Douglas L. Beck:

I think you're right and I do believe this is. You just opened the floodgates on this. Dr Serschfeld, thank you once again for joining us on the Hearing Matters podcast. I will look forward to hopefully catching up with you in New Orleans at the AAA meeting and, other than that, I wish you a safe flight and enjoy this week.

Dr. Grant Searchfield:

Great Thanks to you, Doug, and all your listeners. Hopefully they'll find it interesting.

People on this episode

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Blaise M. Delfino, M.S. - HIS

Host
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Dr. Douglas Beck

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