Tinnitus and anxiety: why the ringing gets louder under stress

“During the day I hardly hear it. Then I switch off the light and it’s back — as if someone had left a television on in the room with no programme.”

That is how tinnitus was once described by someone who had been living with it for several years. Ringing, whistling, hissing or buzzing in the ears that nobody else can hear. Most of the time it stays in the background, but it has a strange quality: it is loudest exactly when you most want silence. Before sleep. In the week when everything at work is falling apart. After an argument with someone close. When tension is at its highest, the ringing “turns up the volume”.

People with tinnitus notice this themselves, and it often unsettles them even more. If the sound gets louder under stress, does that mean they are imagining it? Or that the condition is getting worse? In this post I want to explain what we know about the link between tinnitus and anxiety, why that link is real and physical rather than imagined — and what can help when the sound cannot be switched off.

See a doctor first — and when to go quickly

Tinnitus is not an illness but a symptom. Behind it there may be hearing loss caused by noise or age, a blocked ear canal, an infection, certain medicines, problems with the jaw joint, high blood pressure and, more rarely, conditions that need prompt attention. So the first step is always a conversation with your GP, who will refer you to an ear, nose and throat specialist if needed, where your ears are examined and your hearing is tested.

With some signs, don’t wait:

• if the tinnitus came on suddenly in one ear, especially together with a feeling of blockage or reduced hearing — sudden hearing loss is a condition where time matters;
• if the sound pulses in time with your heartbeat;
• if it comes with dizziness, weakness in the face, difficulty speaking or other neurological signs;
• if it appeared after a head injury.

Once physical causes have been examined and it is clear there is no danger, many people are left with a sound the doctor cannot remove. That is where the second part of the story begins — the one in which anxiety plays an important role. I have set out more general thoughts on what it means when the tests are normal but the symptom remains in “The tests are normal, but it still hurts”. Here I will focus on what is specific to tinnitus.

The sound is one thing, the distress another

Tinnitus is common. A large review that pooled data from many countries estimated that around 14 per cent of adults have it. But only a small share of them — around two per cent of all adults — experience it as severely bothersome. Most people with tinnitus live with it by noticing the sound now and then and then forgetting about it.

This may be the most important insight in the whole field: what matters is not so much how loud the sound is, but how you respond to it. Researchers have repeatedly found that the measured loudness of tinnitus is a poor predictor of how much a person suffers. Two people can have a similar sound — one barely notices it, the other cannot sleep because of it.

Something similar was shown as far back as the 1950s. Two researchers sat people with no hearing problems in a soundproof room for a few minutes. In complete silence, almost all of them began to hear hissing, humming or whistling — sounds nobody was playing. A brain deprived of outside sounds starts to “listen” to its own noise. For most people this never turns into a problem, because they do not experience those sounds as important.

How the brain decides which sound matters

The brain filters constantly. You don’t hear the hum of the fridge, the fan in your computer or the traffic outside the window until someone points them out. These sounds are there all the time, but they have been classified as unimportant. This is called habituation.

Around 1990 the American neuroscientist Pawel Jastreboff described a model that became the foundation of the modern understanding of tinnitus. In his view, tinnitus becomes troublesome when the signal in the auditory system becomes linked with the systems that handle emotion and the response to danger. Once the brain labels the sound as a threat, it stops filtering it out. On the contrary — it pays attention to it, monitors it, checks it. And the more it monitors it, the more present it becomes.

This is the heart of the answer to the question in the title. When you are under stress, your nervous system is in a state of heightened alertness. The body scans its surroundings and its insides for signs of danger. A sound you would normally filter out then slips through the filter — not because anything has changed in the ear, but because the brain is set to look for trouble. I have written about how anxiety changes the way the brain works, and why the body reacts before you think, in What happens in the brain during anxiety.

Thoughts that turn the ringing up

The researchers who developed the cognitive-behavioural model of tinnitus described typical thoughts that feed it. You will recognise them if you live with it:

• “It will never go away.”
• “This is going to drive me mad.”
• “If I don’t sleep, I won’t cope tomorrow.”
• “There must be something worse behind it that they’ve missed.”
• “I have to find silence, or it will get worse.”

Each of these thoughts is understandable. But each has a similar effect: it increases the sense of threat and steers attention back to the sound. This is a classic example of catastrophising — when the brain draws the worst possible outcome from an unpleasant sensation.

Alongside the thoughts comes behaviour. People with severely bothersome tinnitus often start checking whether the sound is still there. They avoid quiet rooms, and loud ones too, for fear the condition might get worse. They stop going to concerts, the cinema, family gatherings. Every such act of avoidance brings relief for a moment, but in the long run tells the brain that the sound really is dangerous.

For some people tinnitus becomes entangled with health anxiety: every change in the sound sets off an online search and a new round of worry. If you recognise yourself in this, you may find Health anxiety: when every symptom means the worst helpful.

Night is the hardest

Most people with tinnitus will tell you the evening is worst. There are several reasons. There are fewer outside sounds, so the inner one stands out more. Tiredness reduces the brain’s capacity to filter. And night is the time when thoughts about the day that has been and the day to come start spinning anyway.

This is where the circle closes. Tinnitus makes it harder to fall asleep, poor sleep increases sensitivity to stress, stress increases the perception of tinnitus. Many people begin going to bed already tense, because they expect a struggle. I have written about what happens in the nervous system when the brain won’t let go of the day in Insomnia: what happens in the nervous system when the brain won’t let go of the day.

A common piece of advice from tinnitus specialists is to avoid complete silence. A quiet, steady background sound — the whirr of a fan, soft music, the sound of rain — does not cover the tinnitus completely, but it reduces the contrast between it and its surroundings. The aim is not to stop hearing the sound, but to make it stand out less.

How this shows up in conversation

In therapy, tinnitus is rarely talked about only as a sound. What often emerges is everything that has piled up around it. A conversation might go like this (a composite, not a real person):

“The worst is when I get home. Everyone’s loud, and I just wait for them to go to bed so I’ll have some peace. And then it’s quiet and I hear it even more.”
“What happens inside you when you hear it in that quiet?”
“Anger. As if it’s taken away the one hour I had left.”
“What was that hour for you, before the tinnitus came?”
“The only time I didn’t owe anybody anything.”
“It sounds as if it isn’t only about the sound. It’s also that this hour doesn’t exist anywhere else any more.”

In a moment like that, the story widens. The tinnitus remains, but next to it a tiredness that was hidden before becomes visible: days with no space for yourself, relationships with no rest in them, a need nobody had words for. When that begins to be addressed, the ringing often doesn’t disappear — but many people find they start to notice it less.

What research shows about what helps

For chronic tinnitus there is currently no medicine that reliably removes it. What does have solid evidence is help with how the sound affects your life.

A Cochrane review, which gathered randomised studies of cognitive behavioural therapy for tinnitus, found that it reduces the impact of tinnitus on quality of life and somewhat reduces anxiety and depressive symptoms too. It does not change the loudness of the sound. This is important to understand: the goal is not silence, but less suffering alongside the sound. American clinical guidelines for tinnitus therefore recommend cognitive behavioural therapy, while advising against routinely prescribing medication with the aim of making the sound go away.

A growing body of research also looks at acceptance-based approaches, such as acceptance and commitment therapy. Their logic is similar: instead of fighting the sound, you learn how to let it be while you return to the things that matter to you.

In therapy as I practise it, we also turn to something else: what is happening in your life and relationships when the ringing is at its loudest. When it began, what was changing at the time, who in your family knows how you are, and how you talk about it. These conversations don’t remove the sound, but they can reduce the tension that pushes it to the front. I also work with English-speaking clients in person in Ljubljana.

Exercise: from struggle to curiosity

This exercise will not silence your tinnitus. It is meant to shift your relationship with the sound from alarm to observation. Do it during the day, when you are reasonably calm, not for the first time in the middle of the night. It takes ten minutes.

1. Sit comfortably and listen to the sound. Don’t run from it. Describe it to yourself as you would to someone who has never heard it: is it high or low, steady or wavering, in one ear or both?
2. Notice what happens in your body. Do your shoulders rise? Does your jaw clench? Does your breath get shorter? Just notice, don’t correct.
3. Notice the thoughts that appear. Name them: “Here is the thought that it will never go away.” Don’t argue with it; simply recognise it as a thought.
4. Widen your attention. Alongside the tinnitus, find three other sounds in the room, then the feeling of your feet on the floor, then your breath. Let the tinnitus stay, but as one of many impressions, not the only one.
5. To finish, take a few long exhalations and return to your day. Write down how strong the distress was at the start and at the end, from 0 to 10 — not the loudness, the distress.

If you would like an exercise for calming the body that you can also use in the evening, the knowledge base has breathing with a long exhale. More proven ways in which the body calms down are gathered in How the body calms down: methods with evidence, not just advice.

Where this explanation is not enough

I want to be careful here, because the link between tinnitus and stress can easily be twisted into “it’s all in your head”. It isn’t.

Tinnitus is a real perception. In most people it comes with changes in the auditory system, often a hearing loss the person hasn’t even noticed. Anxiety does not create it out of nothing; it affects how much you notice it and how you experience it.

Calming down is not a substitute for medical care. If your tinnitus changes, becomes one-sided, starts pulsing or is joined by new symptoms, go back to your doctor, regardless of how you are doing with stress. For people with hearing loss, a hearing aid can help with tinnitus too, because it gives the brain back outside sounds.

You don’t have to “accept” everything. Accepting the sound does not mean accepting insomnia, exhaustion or a relationship with no room for you. It only means you stop spending your strength on a fight you cannot win, and direct it to where you can change something.

When distress turns into despair — when thoughts come that you can’t go on living with this — talk to someone straight away. In Slovenia you can call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline Zaupni telefon Samarijan on 116 123 (24 hours a day), and in an emergency in Slovenia, 112. Let your doctor know as well; tinnitus that comes with deep low mood needs comprehensive care. If tinnitus comes with tiredness, low motivation and aches around your body, read Depression and the body: pain, fatigue and digestion too.

Similarities with other “loud” symptoms

The mechanism I have described is not unique to tinnitus. It works in a similar way in chronic pain: a nervous system that has been on alert for a long time becomes more sensitive, and a signal it would otherwise filter out is pushed to the front. If you live with both tinnitus and pain, you may find useful parallels in Chronic pain and the nervous system: why pain stays after the wound has healed.

What these conditions have in common is that the symptom lies not only in the organ that perceives it, but also in how the brain interprets it. And that interpretation can be changed — slowly, with patience and often with the help of others.

What to remember

• With tinnitus, see a doctor and have your hearing tested first; sudden one-sided tinnitus, reduced hearing or a pulsing sound need a prompt check.
• Roughly one adult in seven has tinnitus, but it is severely bothersome for only a small share — the difference often lies in the response to the sound, not its loudness.
• Stress does not create the ringing, but it increases attention to it, which is why it seems louder under tension.
• Cognitive behavioural therapy has the best evidence: it doesn’t reduce loudness, but it reduces suffering.
• Instead of complete silence, a quiet background sound helps, along with less checking whether the sound is still there.