Alexithymia, depression and tinnitus in elderly people

Alexithymia in Patients with Somatization Difficulties and Tinnitus-Related Distress: A Systematic Review

Chronic tinnitus, the perception of sound without an external source, can significantly affect individuals' well-being. As an often medically unexplained symptom, chronic tinnitus can present as a "somatoform" or "functional" difficulty. Some evidence has pointed to alexithymia as a transdiagnostically relevant risk factor for both symptom clusters. Using a two-part rapid review-searching within EBSCO, Embase by Ovid, PubMed, Web of Science-we summarize psychological studies regarding alexithymia, i.e., difficulties in recognizing and expressing emotions and (1) somatoform conditions and (2) chronic tinnitus. For the former (inclusion criteria: (1) adult human beings with different kinds of somatization, (2) longitudinal study designs, (3) publication between 2001 and 2021, (4) full-text in English or German) we identified eight studies that revealed significant links between alexithymia and somatoform conditions. Psychotherapy improved alexithymia in most studies. Additionally, alexithymia was associated with broader treatment outcomes such as improvements in pain intensity, gastrointestinal symptoms, and patient-therapist alliance. The 'Risk Of Bias In Non-randomized Studies-of Interventions' tool (ROBINS-I) and 'Revised Cochrane risk-of-bias tool for randomized trials' (RoB 2) were used for risk of bias assessment. Summarizing all available studies on alexithymia and chronic tinnitus, we identified three studies. Inclusion criteria were: (1) adult human beings with chronic tinnitus, (2) publication between 2001 and 2021, (3) full-text in English or German. Risk of bias was assessed by the 'JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies'. The available studies suggested a high rate of alexithymia (65.7%) in patients with chronic tinnitus. Tinnitus-related distress was significantly associated with alexithymia in two studies, one of which, however, found no differences in alexithymia between patients with bothersome versus non-bothersome tinnitus. Conversely, one study reported high levels of alexithymia in patients with low levels of tinnitus-related distress. Overall, alexithymia may be a transdiagnostic psychological indicator of somatization phenomena, which might include some chronic tinnitus presentations. Psychotherapy likely improves alexithymia as well as somatoform symptom presentations.

The relationship between alexithymia and clinical features in rhinoplasty patients

OBJECTIVE

The present study aimed to investigate the incidence of alexithymia in rhinoplasty patients before and after surgery, and to increase the value of alexithymia analysis. The study also aimed to evaluate self-esteem and rhinoplasty outcome scores together.

MATERIAL AND METHODS

Patients who had undergone rhinoplasty were enrolled in the study, and they were grouped according to gender, marital status, working status, indication (functional or aesthetic), and type of surgery (primary or revision). Toronto Alexithymia Scale-20 (TAS-20), Rosenberg Self-Esteem Scale (RSES), Rhinoplasty Outcome Evaluation (ROE), and Nasal Obstruction Symptom Evaluation (NOSE) surveys were used to assess their relationship with alexithymia.

RESULTS

We observed significantly higher alexithymia and lower self-esteem scores in females, widows, those with aesthetic indication, those who required revision surgery, and those who had never worked, and a significant correlation was observed except for marital status (p<0.05). After the surgery, significant improvement was found in TAS-20 and RSES according to preoperative scores (p<0.05). There was a significant inverse correlation between TAS-20 and ROE scores, while a positive correlation was observed between RSES and ROE scores (p<0.05).

CONCLUSION

This is the first study to investigate alexithymia changes in rhinoplasty candidates. TAS-20 can be considered as a useful survey to assess psychological distress in rhinoplasty candidates.

Altered brain responses to emotional facial expressions in tinnitus patients

Tinnitus, the phantom perception of sound, is a frequent disorder that can lead to severe distress and stress-related comorbidity. The pathophysiological mechanisms involved in the etiology of tinnitus are still under exploration. Electrophysiological and functional neuroimaging studies provide increasing evidence for abnormal functioning in auditory but also in non-auditory, e.g., emotional, brain areas. In order to elucidate alterations of affective processing in patients with chronic tinnitus, we used functional magnetic resonance imaging (fMRI) to measure neural responses to emotionally expressive and neutral faces. Twelve patients with chronic tinnitus and a group of 11 healthy controls, matched for age, sex, hearing loss and depressive symptoms were investigated. While viewing emotionally expressive faces compared to neutral faces brain activations in the tinnitus patients differed from those of the controls in a cluster that encompasses the amygdala, the hippocampus and the parahippocampal gyrus bilaterally. Whereas in controls affective faces induced higher brain activation in these regions than neutral faces, these regions in tinnitus patients were deactivated. Our results (1) provide evidence for alterations of affective processing of facial expressions in tinnitus patients indicating general domain-unspecific dysfunctions in emotion processing and (2) indicate the involvement of medial temporal areas in the pathophysiology of tinnitus.

Auditory sensation with affective agnosia: A prevalence of alexithymia among tinnitus patients

OBJECTIVES

The aim of the present study was to determine the prevalence and association of alexithymia, depression, and anxiety in patients affected by tinnitus.

METHODS

The study was conducted among the patients referred for audiometric evaluation for tinnitus. They were further evaluated with the Hospital Anxiety and Depression Scale, the Tinnitus Handicap Inventory, and the Toronto Alexithymia Scale. Analysis was done for prevalence and the sample was categorized as high and low tinnitus handicap subgroups, and mean scores of alexithymia, anxiety, and depression were compared.

RESULTS

A total of 70 patients (55.7% - male and 44.3% - female) with a mean age of 33.17 ± 12.24 years were finally analyzed. The severity of tinnitus was most severe (34.3%), followed by moderate (20%), catastrophic (18.6%), mild (17.1%), and slight (10%). The prevalence of alexithymia, anxiety, and depression among patients of tinnitus was found to be 65.7%, 37.1%, and 20%, respectively. The high tinnitus handicap group showed higher scoring on total alexithymia score, anxiety, and depression and higher scoring with describing emotion and identification of emotion, but there was no difference for the subscale of externally oriented thinking.

CONCLUSIONS

The study found a prevalence of alexithymia, anxiety, and depression as 65.7%, 37.1%, and 20%, respectively, among patients of tinnitus, and problem of describing and identification of emotion are associated with higher tinnitus handicap.

Depression in Patients with Tinnitus: A Systematic Review

OBJECTIVE

Tinnitus is a condition that causes distress and impairment across cognitive, functional, and psychiatric spectra. In the psychiatric realm, tinnitus has long been associated with depression. To better characterize the co-occurrence of depression and tinnitus, we performed a systematic review of the prevalence of depression among patients with tinnitus.

DATA SOURCES

We comprehensively examined original studies reporting the prevalence of depression in adult populations with tinnitus, as indexed in the PubMed and Web of Science databases and published from January 2006 to August 2016.

REVIEW METHODS

All identified articles were reviewed independently by 2 researchers, with a third reviewer for adjudication. Included studies were evaluated for threats to validity across 3 domains-representativeness, response rate, and ascertainment of outcome-on a 4-point modified Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Twenty-eight studies were included, representing 15 countries and 9979 patients with tinnitus. Among the included studies, the median prevalence of depression was 33%, with an interquartile range of 19% to 49% and an overall range of 6% to 84%. Studies were high quality overall, with a mean score of 3.3 (SD = 0.76), and 89% utilized a validated tool to ascertain depression.

CONCLUSIONS

We conducted one of the largest contemporary comprehensive reviews, which suggests a 33% prevalence of depression among patients with tinnitus. Our review reaffirms that a substantial proportion of patients with tinnitus have depression, and we recommend that all who treat tinnitus should screen and treat their patients for depression, if present.

Alexithymia Is Associated with Tinnitus Severity

OBJECTIVE

Alexithymia is considered to be a personality trait with a tendency to express psychological distress in somatic rather than emotional form and, therefore, may play a vital role in somatization. Although, such a propensity can be found in patients suffering from tinnitus, the relationship between alexithymic characteristics and the subjective experience of tinnitus severity remains yet unclear. Our aim was to evaluate which alexithymic characteristics are linked to the subjective experience of tinnitus symptomatology.

METHODS

We evaluated tinnitus severity (Tinnitus Handicap Inventory, THI), alexithymia (20-item Toronto Alexithymia Scale, TAS-20), and depression (Beck Depression Inventory, BDI) in 207 outpatients with tinnitus. Correlation analyses and multiple regression analyses were calculated in order to investigate the relationship between alexithymic characteristics, tinnitus severity, and depression.

RESULTS

Highly significant positive correlations were found between THI total score and TAS-20 total score as well as BDI score. Regarding the TAS-20 subscales, multiple regression analyses showed that only the TAS-20 subscale "difficulty in identifying feelings" (DIF) and the BDI significantly predicted the subjective experience of tinnitus severity. Regarding the THI subscales, only higher scores of the THI subscale "functional" demonstrated an independent moderate association with higher scores for DIF.

CONCLUSION

We found an independent association between the subjective experience of tinnitus severity and alexithymic characteristics, particularly with regard to limitations in the fields of mental, social, and physical functioning because of tinnitus and the difficulty of identifying feelings facet of alexithymia. These findings are conducive to a better understanding of affect regulation that may be important for the psychological adaptation of patients suffering from tinnitus.

The Relevance of Interoception in Chronic Tinnitus: Analyzing Interoceptive Sensibility and Accuracy

In order to better understand tinnitus and distress associated with tinnitus, psychological variables such as emotional and cognitive processing are a central element in theoretical models of this debilitating condition. Interoception, that is, the perception of internal processes, may be such a psychological factor relevant to tinnitus. Against this background, 20 participants suffering from chronic tinnitus and 20 matched healthy controls were tested with questionnaires, assessing interoceptive sensibility, and participated in two tasks, assessing interoceptive accuracy: the Schandry task, a heartbeat estimation assignment, and a skin conductance fluctuations perception task assessing the participants' ability to perceive phasic increases in sympathetic activation were used. To test stress reactivity, a construct tightly connected to tinnitus onset, we also included a stress induction. No differences between the groups were found for interoceptive accuracy and sensibility. However, the tinnitus group tended to overestimate the occurrence of phasic activation. Loudness of the tinnitus was associated with reduced interoceptive performance under stress. Our results indicate that interoceptive sensibility and accuracy do not play a significant role in tinnitus. However, tinnitus might be associated with a tendency to overestimate physical changes.

Tinnitus and its association with psychiatric disorders: systematic review

Objectives:

To systematically review the literature on the occurrence of psychiatric diagnoses in a tinnitus-affected population, and correlate the presence of psychiatric disorders with tinnitus-related annoyance and severity.

Method:

A systematic review of the literature published between January 2000 and December 2012 was performed using PubMed, ISI Web of Science and SciELO databases. Original articles in English and Portuguese that focused on the diagnosis of mental disorders associated with tinnitus, especially anxiety and depression, were identified.

Results:

A total of 153 articles were found and 16 were selected. Fifteen articles showed a high prevalence of psychiatric disorders in tinnitus-affected patients, and nine showed a high correlation between the presence of a psychiatric disorder and tinnitus-related annoyance and severity.

Conclusion:

The prevalence of psychiatric disorders, especially anxiety and depression, is high in tinnitus patients, and the presence of these disorders correlates with tinnitus-related annoyance and severity.

Association between depression and tinnitus in a nationally representative sample of US older adults

OBJECTIVES

Few population-based studies examining the association between tinnitus and depression among older adults have been conducted. Therefore, the purpose of this study was to examine the association between tinnitus and depression among a nationally representative sample of US older adults.

METHODS

Data from the 2005-2006 National Health and Nutrition Examination Survey was used. 696 older adults (70-85 yr) completed questionnaires on tinnitus and depression, with depression assessed using the Patient Health Questionnaire-9.

RESULTS

After controlling for firearm use, age, gender, race-ethnicity, cardiovascular/stroke history, diabetes, smoking status, body mass index, physical activity, noise exposure and elevated blood pressure, there was a significant positive association (beta coefficient: 1.28, 95% CI: 0.26-2.29, p = 0.01) between depression and tinnitus being at least a moderate problem, suggesting that those who perceived their tinnitus to be a moderate problem were more likely to be depressed than those perceiving it to be a small or no problem. Additionally, after adjustments, those who were bothered by tinnitus when going to bed were 3.06 times more likely to be depressed than those who were not bothered by tinnitus when going to bed (OR = 2.44, 95% CI: 1.03-5.76, p = 0.04).

CONCLUSION

These findings suggest that individuals who perceive their tinnitus to be a problem or have problems with tinnitus when going to bed may be in need of intervention to prevent or reduce their depression symptoms so as to ensure that other areas of their life are not negatively influenced.

Tinnitus: clinical experience of the psychosomatic connection

BACKGROUND

The connection between psychopathology and tinnitus is complex and not adequately studied. The aim of this study is to investigate the relationship between tinnitus and psychiatric comorbidities from different points of view: categorical, dimensional, temperamental, and perceived stress level.

METHODS

Two hundred and thirty-nine patients affected by tinnitus were recruited between January and October 2012. Patients underwent a preliminary battery of tests including the Tinnitus Handicap Inventory (THI), Symptom Check List (SCL90-R), Temperament and Character Inventory (TCI), and Stress-Related Vulnerability Scale (VRS), and eventually a full psychiatric evaluation.

RESULTS

One hundred and fourteen patients (48% of the total sample) presented psychiatric comorbidity. Among these, a higher prevalence of depression, somatization, obsession, and anxiety was found. More than 41% of patients affected by decompensated tinnitus reported a family history of psychiatric disorders. Significant positive correlations between the psychopathological screening tools (SCL90-R and VRS) and THI were found. Patients affected by comorbid psychiatric disorder showed specific temperamental and characterial predispositions.

CONCLUSION

Psychiatric comorbidity in subjects affected by tinnitus is frequent. Stress can be considered as a factor leading to damage and dysfunction of the auditory apparatus. The vulnerability to neurotic disorders and the lack of coping capabilities can play a critical role in the clinical history of patients affected by severe tinnitus.

Noise-induced tinnitus using individualized gap detection analysis and its relationship with hyperacusis, anxiety, and spatial cognition

Tinnitus has a complex etiology that involves auditory and non-auditory factors and may be accompanied by hyperacusis, anxiety and cognitive changes. Thus far, investigations of the interrelationship between tinnitus and auditory and non-auditory impairment have yielded conflicting results. To further address this issue, we noise exposed rats and assessed them for tinnitus using a gap detection behavioral paradigm combined with statistically-driven analysis to diagnose tinnitus in individual rats. We also tested rats for hearing detection, responsivity, and loss using prepulse inhibition and auditory brainstem response, and for spatial cognition and anxiety using Morris water maze and elevated plus maze. We found that our tinnitus diagnosis method reliably separated noise-exposed rats into tinnitus⁽⁺⁾ and tinnitus⁽⁻⁾ groups and detected no evidence of tinnitus in tinnitus⁽⁻⁾ and control rats. In addition, the tinnitus⁽⁺⁾ group demonstrated enhanced startle amplitude, indicating hyperacusis-like behavior. Despite these results, neither tinnitus, hyperacusis nor hearing loss yielded any significant effects on spatial learning and memory or anxiety, though a majority of rats with the highest anxiety levels had tinnitus. These findings showed that we were able to develop a clinically relevant tinnitus⁽⁺⁾ group and that our diagnosis method is sound. At the same time, like clinical studies, we found that tinnitus does not always result in cognitive-emotional dysfunction, although tinnitus may predispose subjects to certain impairment like anxiety. Other behavioral assessments may be needed to further define the relationship between tinnitus and anxiety, cognitive deficits, and other impairments.

Tinnitus severity and the relation to depressive symptoms: a critical study

OBJECTIVE

In this study, the authors investigated whether tinnitus severity is a problem related to depression. If so, the following 2 conditions should be fulfilled: first, there should be evidence for the presence of moderate to severe depressive symptomatology in a substantial group of tinnitus patients; second, there should be evidence of a substantial relationship between depressive symptoms and tinnitus severity.

STUDY DESIGN

Cross-sectional.

SETTING

Ear, Nose, and Throat (ENT) Department of the Ghent University Hospital.

SUBJECTS AND METHODS

In total, 136 consecutive help-seeking tinnitus patients were seen by a psychologist, an audiologist, and an ENT specialist. All patients filled in the Beck Depression Inventory II (BDI-II) and the Tinnitus Handicap Inventory (THI) and underwent psychoacoustic measurement.

RESULTS

Mean scores indicate the presence of no or minimal depressive symptoms. There was a positive correlation (P < .01) between the BDI-II and the THI. No correlations were found between psychoacoustic measures and the self-report questionnaires. Linear regression analysis was performed to examine the predictive role of the 3 components of depression (cognitive, somatic, and affective) in tinnitus severity. Results show that only the somatic depression subscale of the BDI-II significantly predicted tinnitus severity, which can be explained because of content overlap between the BDI-II and the THI.

CONCLUSION

Tinnitus does not appear to be a problem related to depression. The authors did not find a substantial group of tinnitus patients with moderate to severe depressive symptoms. The relation between depressive symptoms and tinnitus severity seems to be an artifact of content overlap between the BDI-II and the THI.

The association between tinnitus and mental health in a general population sample: results from the HUNT Study

OBJECTIVES

Clinical studies indicate a strong association between tinnitus and mental health, but results from general population data are missing. The purpose of the study was to examine the association between tinnitus, mental health, and well-being in the general adult population and to identify factors that might mediate and moderate this association.

METHODS

Data from 51,574 adults participating in the Nord-Trøndelag Hearing Loss Study (1995-1997), part of the Nord-Trøndelag Health Study (HUNT-2), were analyzed. The association between tinnitus symptom intensity and symptoms of depression, anxiety, self-esteem, and subjective well-being was examined by multivariate ANOVA, stratified by age group and sex. Explanatory variables were age, marital status, education, hearing, dizziness, vision, physical disability, and somatic illness. In a subsample of participants with tinnitus, the effects of "time since onset," "predictability of tinnitus episodes," and "noise sensitivity" were tested.

RESULTS

Participants with tinnitus scored significantly higher on anxiety and depression and lower on self-esteem and well-being than people without tinnitus. The effect sizes were small and quite similar across levels of tinnitus symptom intensity. No significant effect of time since onset was found. A significant effect of predictability of tinnitus episodes and noise sensitivity was found in some groups.

CONCLUSION

A weak association between tinnitus and mental health was found in this general population study.