Suicidal Ideation and Tinnitus

Welcome to the first entry in Sound Mind, a series dedicated to exploring the psychological dimensions of hearing disorders. I thought we would start with a discussion about suicidal ideation (SI) and tinnitus, starting with this epidemiological finding: Tinnitus sufferers experience suicidal ideation (SI) at about twice the rate of the general population, even though the rate of death by suicide itself is not elevated [1].

While depression is a common comorbidity, there may be value in considering SI in tinnitus as a distinct neurobiological phenomenon. In understanding tinnitus-related SI, two brain networks stand out: the default mode network (DMN) and the salience network (SN). Both play critical roles in processing SI-related psychological distress, and recent research suggests they are also involved in the pathophysiology of tinnitus itself [2].

Distinct brain networks mediate tinnitus suffering.

Source: OpenArt/Hamid Djalilian

The Default Mode Network and Tinnitus

The Default Mode Network can be described as the neural basis for our baseline self-awareness. In some tinnitus patients, this DMN facilitates the incorporation of persistent tinnitus suffering into one’s self-identity. In these patients, the brain, through DMN, treats the tinnitus experience as intrinsic—a constant, inescapable aspect of the self.

This embedding of tinnitus within the DMN can lead to persistent suffering, as the ringing is perceived not just as an unwelcome sound but as a source of personal distress that is inseparable from one’s residual self. As a result, SI may emerge from the feeling that there is no escape from the tinnitus suffering that has now become an integral part of one's self-perception.

The Salience Network and Tinnitus

The SN helps evaluate the emotional significance of stimuli and identifies what information demands attention and what can be ignored. In tinnitus, the SN can misinterpret the ringing sound as a threatening signal, leading the brain to assign it high-priority status. This misinterpretation causes the tinnitus sound to feel intrusive, creating a sense of urgency to address or “fix” the sound.

For some tinnitus sufferers, this prioritization by the SN leads to feelings of helplessness and emotional exhaustion. The SN flags the tinnitus as a source of distress that demands constant monitoring, which fosters a cycle of hypervigilance. In other words, tinnitus becomes an ongoing, unsolvable and distressful problem.

The Default Mode Network-Salience Network Interaction in Tinnitus-Related Suicidal Ideation

In chronic tinnitus, the interaction between the DMN and SN appears to deepen the experience of SI [3]. With the DMN embedding the tinnitus as part of self-identity and the SN interpreting it as a constant threat, some sufferers get caught in a double bind: tinnitus becomes both an inseparable aspect of self and an urgent problem that demands attention. This dual burden leads to a mental state where some tinnitus sufferers experience both profound distress and a sense of entrapment. This is fertile ground for the emergence of SI.

Neuroimaging studies have identified altered connectivity within the SN and DMN in cases of SI, where these networks contribute to intrusive thoughts and heightened personal distress [4]. The connectivity patterns in these networks during SI are distinct from those involved in suicidal actions, suggesting that while SI arises from DMN and SN dysfunctions, progressing from SI to action necessarily involves further impairments, particularly in cognitive control networks [5]. This highlights SI as a distinct neuropsychiatric phenomenon, separate from the mechanisms underlying suicidal actions.

This suggests a narrative where in some cases of tinnitus-related SI, the DMN internalizes tinnitus suffering as part of the self, while the SN emphasizes its importance as a threat. This unique interaction leaves some with tinnitus feeling trapped in a cycle where the tinnitus sound is both a personal burden and an inescapable source of suffering, setting the stage for SI as a maladaptive form of problem-solving, a solution to an unsolvable problem.

Suicide Essential Reads

The Soul Knows When It's Time to Go

The Correlation Between Suicide and the Seasons

Implications for Treatment: Targeting Network Dysregulation

Understanding tinnitus-related SI through the lens of DMN and SN dysfunction suggests specific therapeutic approaches. Rather than treating SI in tinnitus solely as an extension of depression, treatments should focus on reducing the DMN’s integration of tinnitus as part of the self (through cognitive behavioral therapy, for instance) and the SN’s urgent signaling of it as a threat (through treatments to reduce tinnitus loudness).

The new understanding that tinnitus loudness is due to a central sensitivity caused by an atypical migraine process (active migraine without a headache), has made tinnitus medically treatable [6]. Once tinnitus loudness stabilizes, neural network reorganization in the DMN and SN becomes much more feasible. In other words, multimodal treatment of tinnitus presents an optimal approach. By combining the medical management of tinnitus to reduce loudness with psychological and network-targeted interventions to reduce suffering, we can better support those suffering from this condition.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.