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Challenge Your Negative Thoughts

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    Watch this video before starting the module

    Module ID iCBT for Tinnitus self-help, Module number 4
    Title Challenge Your Negative Thoughts
    Author

    Dr. Hashir Aazh
    (Tinnitus and Hyperacusis Team-lead at the Royal Surrey County Hospital)

    Collaborators

    Professor Brian C.J. Moore
    (Department of Psychology, University of Cambridge)

    Dr Fiona Seaman-Thornton
    (Clinical Psychologist at the Royal Surrey County Hospital)

    Duration 37 pages

    Terms and conditions: By accessing this module you consent to (1) adhere to Copyright regulations (i.e., not to reproduce or copy any parts of this programme without written permission from the author), (2) you understand that we do not keep any identifiable information but anonymised data will be used for service improvement and research, (3) the email address you provide will be used for forwarding you the assessment reports, CBT information and worksheets relevant to your iCBT treatment and future communications in order to inform you about research updates, new services, future events, and tinnitus-related news (4) Like most websites we use cookies to deliver a personalised service, (5) For full information about our policies click on the relevant links here: Terms and conditions, Copyright, Privacy policy, Cookies policy, Medical information disclaimer.


    Audio version of the module

    This is the audio recording of Dr Hashir Aazh reading out loud the text of this module and offering some further explanations. You may listen to this audio recording before, during, or after completing this model. This is a supplementary feature that is aimed to improving your learning experience.

    Challenge your negative thoughts

    Tinnitus is defined as the perception of sound in the absence of an acoustical sound source. There is no definitive cure for tinnitus at present, i.e., no method that eliminates the tinnitus itself. However, people often benefit from various forms of therapy that help them to lead a normal life despite continuing to experience tinnitus. When tinnitus no longer affects your life, then it loses its significance and is more likely for it to fade away into the background as opposed to staying at foreground of your attention. In the next page we discuss how CBT can help.

    How CBT can help

    Cognitive behavioural therapy (CBT) is a psychological treatment that aims to minimise the effect of tinnitus on your daily life via teaching you a certain set of skills that help you to explore and modify some of your negative thoughts about tinnitus, and change your behaviours that follow on from those thoughts. Pervious modules in this iCBT programme aimed to help you to identify your negative thoughts about tinnitus. The aim of this module is to teach you how to challenge your thoughts.

    Module Objectives

    By the end of this module, you should be able to:

    • Describe the relationship between tinnitus, anxiety and negative thoughts
    • Differentiate the levels of thoughts: automatic thoughts, rules of life and core beliefs
    • Explain the mechanism by which tinnitus perception can lead to distress based on the levels of thoughts
    • List the 10 common forms of cognitive distortion
    • Differentiate different forms of cognitive distortion
    • Identify errors of judgment in your own tinnitus-related perceptions

    Why is my tinnitus at the foreground of my attention and why doesn’t it fade away into the background?

    For many people, tinnitus does fade away into the background with the passage of time. However, this does not happen for everyone experiencing tinnitus. If you have enrolled in this iCBT programme then it is likely that the latter applies to you. So you may ask "Why is my tinnitus at the foreground of my attention and why doesn’t it fade away into the background?"

    How our brain prioritises our awareness of various sensations

    Here is some information that might help you to understand how our brain prioritises our awareness of various sensations and the relevance of this to tinnitus.

    For many types of “external” stimuli (sensations that we can notice), the stimuli are noticed when they first occur, but if they remain steady and if they have no negative associations, then awareness of them fades over time. For example, the steady background noise from a computer fan may be unnoticed after a time. This process of fading from awareness is called adaptation or habituation.

    Why is my tinnitus at the foreground of my attention and why doesn’t it fade away into the background?

    So essentially our brain should habituate to tinnitus and put it into the background with the passage of time. However, the tinnitus-related anxiety, fear and annoyance that we can experience can prevent the natural process of habituation. This is an evolutionary feature, which also is the case for external sounds. There is no way that your brain can get used to a sound which is a sign of danger.

    How the brain ignores unthreatening sounds

    For example, it is impossible to ignore a sound of a snake hissing if there was one in the corner of your room. Such a hissing noise is a sign of danger and your brain would focus on it. In fact, your brain would not allow you to keep reading this module and you would have a fight and flight response (I will be on my desk screaming for help!). On the other hand, it would be possible for you to get used to such a sound if the snake was your pet and you developed the belief that the hissing sound was normal and did not signal any danger to you.

    What does research say?

    There are several research studies indicating that the processing of emotionally significant stimuli in the brain is enhanced in comparison with the processing of neutral stimuli. This means that when tinnitus induces negative emotions, such as anxiety, fear, annoyance, anger, or guilt, then it is more likely to be perceived and to remain the focus of attention than if it does not evoke negative emotions. CBT assumes that the negative emotions are not necessarily due to perceiving tinnitus but are mainly a result of the individual’s negative thoughts about tinnitus.

    In the next few pages, examples of negative thoughts that can induce negative emotions about tinnitus are given.

    The relationship between thoughts about tinnitus and our emotional reaction

    The table in the next page lists examples of negative thoughts about tinnitus leading to certain negative emotions. As the result of various tinnitus-related negative thoughts, a wide range of negative emotions from hopelessness to terror can be experienced. Recall that if tinnitus induces negative emotions, such as anxiety, fear, annoyance, anger, or guilt, then it is more likely to be perceived and to remain the focus of attention than if it does not evoke negative emotions. Later on in this module, we will teach you methods to effectively modify such negative thoughts. But at this stage it is vital to gain more understanding about the nature and complexities of the negative thoughts.

    See the next page for a table of thoughts and emotions about tinnitus.

    Table of thoughts about tinnitus and our emotional reactions

    Thought
    Likely Emotion
    Tinnitus will drive me mad
    Fear
    Tinnitus means that I have a serious problem with my hearing
    Fear
    Tinnitus prevents me from sleeping
    Frustration, anxiety
    Tinnitus is a little beast stealing my happiness
    Resentment
    Tinnitus will ruin my life
    Fear, anger
    I won’t be able to lead a normal life because of the tinnitus
    Hopelessness
    Tinnitus lowers my standards of work
    Irritation, anxiety
    Tinnitus prevents me from hearing people
    Annoyance, frustration
    I am not normal anymore
    Disappointment, anxiety
    I cannot cope with my tinnitus because I am a failure
    Hopelessness
    Tinnitus is a demon, viciously attacking me and screaming loud as it cannot get out of my head
    Terror
    Tinnitus is a torture noise
    Resentment

    In the next page, you can read more about different layers of cognitions/thoughts.

    What are the different layers of cognitions?

    According to Aaron Beck there are three layers of cognitions comprising: automatic thoughts, rules of life, and the core beliefs.

    The graph to the right illustrates the cognition layers.

    Automatic thoughts link directly to emotional reactions. They spontaneously arise, without any prior reasoning, and flow rapidly through our mind.

    Emotional disturbances and the layers of cognitions

    In people who suffer from anxiety, depression and other psychological disorders, automatic thoughts can become distorted. Cognitive distortions are systematic errors in logic derived from maladaptive attitudes or rules of life. During the course of cognitive development throughout life, individuals create various rules of life in order to regulate their emotions and behaviour.

    Rules of life are tied to an individual’s core beliefs. Core beliefs are typically formed in childhood and are the deepest level of cognition and the most basic assumption about our identity, the world around us and the future. Core beliefs are created based on the child’s interpretation of their life events.

    In the next page more explanations about the interaction between core beliefs, rules of life and automatic thoughts are offered.

    Interaction between core beliefs, rules of life, and automatic thoughts

    Early life experiences lead to the development of positive (e.g., “I am good”, “I am worthy”) and negative core beliefs (e.g., “I am unlovable”, “I am incompetent”). Although some core beliefs appear dysfunctional and negative, they may have been adaptive for children during their early years when managing a negative or hostile environment. However, taken outside of this environment, these core beliefs become maladaptive and lead to the dysfunctional application of rules for living and consequent maladaptive behaviours.

    Interaction between core beliefs, rules of life, and behaviour

    For example, if a child develops the core belief “I am a nuisance”, they may also develop a rule of life that “I should always be quiet”. This may help to keep them safe and prevent conflict with their family when they are young. However, they may continue to behave in line with this rule of life in other situations and these beliefs may continue into adulthood where they may affect that person’s relationships with other people.

    Positive core beliefs can promote the flexible application of rules of life and may be more likely to lead to a more realistic appraisal of threat.

    In the next page, more information on the interaction between cognitive layers and tinnitus-related distress is presented.

    Interaction between cognitive layers and tinnitus-related distress

    In the context of CBT for tinnitus, your emotional reaction to tinnitus is explained in the following way. For instance, you may think that tinnitus affects your concentration and reduces your efficiency at work, thereby leading to the catastrophic conclusion that you will never work again to your own standards. This is an example of a negative automatic thought (NAT). But why do such NATs create anxiety in some people and not in other? See the next page for more information on the conflict between layers of cognitions that can explain this.

    Conflict between cognitive layers and tinnitus-related distress

    This negative thought (I will never work again to my own standards) violates rules and assumptions you have established across your life span, such as “in order to survive I should always be at my peak efficiency”. These rules of life are in turn assumed to reflect a core belief (e.g., I am a failure). The onset of tinnitus can precipitate a perceived threat to these life rules. This leads to tinnitus-related anxiety and depressed mood.

    The next page gives examples of common dysfunctional rules of life.

    Examples of dysfunctional rules of life

    Examples of dysfunctional rules of life introduced by Aaron Beck:

    I should never feel hurt.

    I should always be happy and serene.

    To be happy I must be accepted, liked, admired by all people at all times.

    My value as a person depends on what others think of me.

    I should always be spontaneous.

    I should always control my feelings.

    I should never be tired or get sick.

    I should never hurt anybody else.

    I should always be at peak efficiency.

    If I make a mistake, it means that I’m inept.

    I should be a perfect lover, friend, parent, teacher, student, and spouse.

    In the next few pages, examples of automatic thoughts and the corresponding rules of life they violate are given.

    The conflict between negative automatic thoughts and rules of life and the corresponding emotional reactions to tinnitus

    The table in the next page illustrates some negative automatic thoughts about tinnitus that violate the rules of life, leading to various negative emotional reactions. In the other words, the conflict between the negative automatic thoughts and the rules of life leads to your emotional reaction to tinnitus. It is important to solve this conflict.

    Recall that if tinnitus induces negative emotions then it is more likely to be perceived and to remain the focus of attention than if it does not evoke negative emotions. In CBT, the idea is to alleviate tinnitus-related distress by modifying the negative automatic thoughts as well as the dysfunctional rules of life.

    Table showing the conflict between negative automatic thoughts and rules of life and the corresponding emotional reactions to tinnitus

    Negative automatic thoughts
    Dysfunctional rules of life
    Emotional reaction
    I cannot fix my tinnitus. I have lost my problem-solving skills.
    "I should be able to find a quick solution to every problem."
    Anxiety
    Tinnitus bothers me a lot and I cannot do anything about it.
    "I should never feel hurt."
    Hopelessness
    Because of my tinnitus I can no longer enjoy my life. I will always be miserable when hearing tinnitus.
    "I should always be happy and serene."
    Depression
    Why me? I do not understand why I have tinnitus.
    "I should know, understand, and foresee everything."
    Anger
    I cannot control my tinnitus or my feelings for it.
    "I should always control my feelings."
    Irritation
    Tinnitus makes me feel tired as I cannot sleep well at nights. Tinnitus is a terrible disease with no cure!
    "I should never be tired or get sick."
    Frustration
    Tinnitus affects my sleep and concentration. Hence it reduces my efficiency. I can no longer be in control at my work place.
    "I should always be at peak efficiency."
    Disappointment
    Tinnitus invades every aspect of my life and makes me feel useless.
    "In order to be happy, I have to be successful in whatever I undertake."
    Irritation
    I make a lot of mistakes because of my tinnitus. Tinnitus is like a fog that affects my performance.
    "If I make a mistake, it means that I’m inept"
    Anxiety

    In the next page, you can read more about different layers of cognitions/thoughts.

    What have we learned so far?

    Based on CBT, if there is a negative core belief (e.g., “I am useless”, “I am unlovable”) there will typically be rigid rules of life that aim to prevent the negative core belief becoming true. For example, “I must always be perfect at my work” or “I must always be kind to others”. Breaking these rules will create a lot of anxiety.

    The perception of tinnitus can lead to negative automatic thoughts such as “I cannot concentrate, therefore I cannot do my work properly” or “tinnitus makes me short tempered, therefore I will be snappy with others”. These negative thoughts break the rules of life and lead to the emergence of tinnitus-related anxiety, which in turn doesn’t allow the process of habituation.

    Another example

    If there is a negative core belief such as “I am not good enough”, there may be rigid rules of life that aim to prevent this negative core belief from becoming true. For example, “I must always avoid challenges” or “I must always control everything”. Breaking these rules will create a lot of anxiety.

    The perception of tinnitus can lead to negative automatic thoughts such as “I cannot control my tinnitus”. This negative thought breaks the rules of life and leads to the emergence of tinnitus-related anxiety which in turn doesn’t allow the process of habituation.

    What if my negative thoughts about tinnitus are true?

    You may believe that the distress you experiencing due to tinnitus is beyond your control. You may ask "How can I possibly feel happy hearing this noise screaming in my ears all the time?" Because of my tinnitus I am not able to concentrate. I cannot do my work and be successful, and that’s reality."

    You may think it is realistic to feel anxious if you have tinnitus, which is a condition with no known cure and completely out of your control.

    Of course there is some truth in all of these thoughts. In fact, our thoughts are influenced by external events, past experiences and our general health and well-being.

    Why do we generate negative thoughts about tinnitus in the first place?

    Our thoughts are influenced by external events, past experiences and our general health and well-being. For example, if you had a stressful day at work, you will be more likely to think that you won’t be able to cope with your tinnitus. Excessive stress at work might put some strain on your coping resources. In the next page we talk about the impact of our past experiences and general health on our thought processes.

    Why do we generate negative thoughts about tinnitus in the first place?

    If based on your past experiences, a family member or a close friend had struggled to cope with tinnitus and it had ruined their life, this can make it more likely for you to have thoughts that if tinnitus gets worse then you won’t be able to manage it. If you already experience poor health or have a less than ideal socio-economic situation, it is more likely for you to think that "I just can’t help feeling helpless due to tinnitus."

    Can I change my thoughts?

    What do you think? Can you change the way you feel about tinnitus or not?

    CBT says that you can change the way you feel.

    What you will learn in the next few pages is that even though you are convinced that your thoughts are true and valid, there can be a lot of errors in them. It is not only your thoughts that can be erroneous. Errors of judgment (the way we respond to distorted thoughts – for example, by assuming that they are always true) are common in all human beings. In fact, errors of judgment might have worked well for us in evolutionary terms. So anyone can experience thoughts that they believe are true but in fact are distorted and unrealistic.

    In the next few pages you will learn about the 10 common form of thought distortion.

    Automatic thoughts and errors

    Automatic thoughts arise with little awareness as to why they arise; they are perceived as strong effects that are not under direct control.

    Aaron Beck suggested that human emotional disturbances are related to a number of distortions in automatic thoughts. These range from over-generalization to all or nothing thinking.

    10 common thought distortions

    This slide shows the common thought distortions, with their definitions and examples.

    10 common thought distortions

    The aim of CBT is not to be happy all the time. Nor that is realistic. The aim is simply to identify and modify the negative thoughts that have inherent errors of judgment. In the other words, the aim of CBT is to change unrealistic and unhelpful thoughts to realistic ones.

    The next few pages will provide an opportunity to examine some common thoughts about tinnitus and find out if they contain any distortions.

    Identify Thought Distortions Quiz

    Select the distortions that you identify in this thought from the list. You can choose more than one from the list.

    Hearing tinnitus always makes me feel tired

    Identify Thought Distortions Quiz

    The thought was "Hearing tinnitus always makes me feel tired."

    Use of “always” in this thought is a sign of over-generalisation. You may feel tired due to tinnitus sometimes, or even frequently but not always. Perhaps the second thought distortion here is the mental filter. A mental filter makes you to focus on all the times that you feel tired (perhaps due to tinnitus). Any time that you are tired and hearing tinnitus will be taken as proof of validity of this thought. However, your mind doesn’t take notice of or filters out the times that you do not feel tired, despite the permanent and continuous nature of your tinnitus. Such thought distortions simply enhance negative thoughts about tinnitus using biased and erroneous information.

    Identify Thought Distortions Quiz

    Mark the distortions that you identify in this thought. You can choose more than one from the list.

    Tinnitus invades every aspect of my life. This makes me useless.

    Identify Thought Distortions Quiz

    The thought was “Tinnitus invades every aspect of my life. This makes me useless.”

    Use of “every” in this thought is a sign of over-generalisation. The second distortion is mental filter. A mental filter makes you focus on all aspects of your life that have been affected by tinnitus. I am useless is an example of labelling. Read more about labelling in the next page.

    Identify Thought Distortions Quiz

    You labelling yourself as useless instead of reviewing what you can achieve and what you can’t. Other examples of labelling are calling yourself a fool, a failure, or a loser. These labels lead to anger, depressed mood, and low self-esteem.

    Labelling can also be connected to other thought distortions. It can be a form of all or nothing thinking, where we as complex human beings are taken out of context and reduced to one characteristic (e.g. if I cannot always concentrate, then I am useless). Labels are also likely to be over-generalised as we assume that we are always like this. This is irrational because, we are much more complex than that.

    Identify errors of judgment in your own thoughts

    Think of the last time that you were bothered by your tinnitus. Of course you may hear your tinnitus constantly, but it may not interrupt your activities or affect your mood all of the time.

    In page 36, use the space under the event column to list the times that your tinnitus was bothering you in the last couple of days (5 events are enough for this exercise). See the next page for further instructions.

    Identify errors of judgment in your own thoughts

    In the table in page 36, in the second column (thoughts) type what went through your mind about your tinnitus in that moment?

    In the third column, type the distortions that you can identify in your thought.

    The aim of this exercise is not to change your thoughts, but to practice identifying your tinnitus-related negative thoughts and their distortions. In the next module (Diary of Thoughts and Feelings) there will be more practice on changing thoughts.

    Identify errors of judgment in your own thoughts

    Different Thought Distortions Reminder

    Event
    Thought
    Distortions

    Magnification: I may be able to follow the programme and rest while watching. Of course it will be much better if I didn’t have tinnitus but I am still enjoying the activity.

    Future telling: How do I know that I will not be able to enjoy TV in the future?

    All or nothing thinking: If I can’t enjoy certain things as well as I used to, then this is taken as indicating that I enjoy nothing.


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