The cortisol awakening response: could this be an effective measure of tinnitus distress?

We’re delighted that Dr James Jackson’s BTA funded research into the connection between cortisol levels on waking and tinnitus has been published in the latest edition of the American Journal of Audiology.

Dr Jackson, associate principle lecturer in psychology at Leeds Trinity University led a pilot study looking at the concentration of the stress hormone cortisol in tinnitus sufferers. 

His evidence suggests that people who report a high level of distress caused by their tinnitus also have a flat diurnal cortisol rhythm which could lead the way to developing more effective interventions. 

Tinnitus is an often debilitating condition that is described as a sensation or awareness of sound that is not caused by a real external sound source. It affects one in eight adults in the UK and there are around 750,000 tinnitus related GP consultations in England each year.  

The condition can greatly impact on a sufferer’s quality of life with approximately half of patients finding it moderately or severely distressing with complaints of intrusiveness emotional stress, insomnia, auditory perceptual problems and concentration problems. 

As part of his study, Dr Jackson asked participants to provide saliva samples first thing in the morning so he could look at stress hormone levels.   

Says Dr Jackson: “Waking up is the time of day when you are secreting the highest concentrations of stress hormones, particularly one called cortisol, in anticipation of the day ahead and I wanted to investigate  the mechanism which produces it.  

“In general, you pump out cortisol first thing, and you reach peak secretion approximately 40 minutes after waking up. Levels then fall back all day, and should be down to nearly nothing at roughly midnight, when you fall asleep and have no energy. There is a set rhythm for this called the diurnal cortisol cycle.  However, it’s already known that if you secrete too much cortisol in the morning it’s an indication that you’re under a lot of stress but secrete too little and it’s more ‘burnout’ – you’ve been anxious/stressed for so long that your body has turned the tap off. Having too much cortisol in the system for too long is very damaging. 

“High levels of cortisol first thing can indicate conditions like anorexia and OCD and low levels can indicate things like depression, chronic pain and chronic fatigue syndrome. 

“My research has been looking at the effect tinnitus has on this morning rhythm and I hypothesised that it would have more in common with conditions such as chronic pain. It’s been a small study but I can conclude that there is evidence suggesting a flat diurnal cortisol rhythm in distressed tinnitus sufferers. Right now, this appears to be related to ‘burnout’ where, due to issues these particular patients have such as a lack of control, an inability to relax and emotional distress caused by the tinnitus, their bodies have shut down cortisol production. 

“The most logical explanation is that this is about whether or not patients feel a sense of control over their tinnitus – those that don’t have a more blunted rhythm than those who do. This suggests three important elements. Firstly, that chronic tinnitus has real physiological effects. Secondly, it is caused by certain aspects of tinnitus which would allow for more targeted intervention and thirdly, that if we can measure distress, we can also measure effectiveness of any interventions.” 

Dr Jackson added: “There is some excitement here about what we have found. Being able to distinguish between the most distressed individuals with tinnitus and those that have adapted more effectively, or have learned to live with their tinnitus would be a huge boon. We can aim to move people from one group to the other, and have an objective, physiological measure of whether the intervention has worked and has increased well-being too.  

“It also suggests real physiological changes in tinnitus patients, and that it is ‘real’. Evidence of physiological change frames tinnitus as being something more than irritation. It is early days though, due to the size and breadth of my study. What’s needed now is funding for a much larger study that can replicate these findings across the board in a more realistic sample.” 

David Stockdale, chief executive of the British Tinnitus Association, said: “When someone first experiences tinnitus it can be very frightening and have an enormous impact on  their  quality of life. Here at the BTA, we are committed to  finding  a cure  for tinnitus  and  in that  vein we  fund a large number  of research projects every year.  We are  really pleased  to hear the results of Dr Jackson’s work and hope more research  can be done in this area.” 


Jackson, J. G. (2019). The cortisol awakening response: A feasibility study investigating the use of the area under the curve with respect to increase as an effective objective measure of tinnitus distress. American Journal of Audiology, 28(3), 583–596. https://doi.org/10.1044/2019_AJA-18-0174

Updated 24 October 2019

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