Emotion dynamics and tinnitus: Daily life data from the "TrackYourTinnitus" application

"I feel [so alone] nothing" - emotional vulnerability and detachment as transdiagnostic key characteristics of patients with chronic tinnitus: a schema mode model approach

Background

Gold-standard approaches for chronic tinnitus involve hearing amplification measures and psychological therapy, where applicable. Whilst schema therapy is accumulating evidence as a transdiagnostically useful treatment framework, its applicability for patients with chronic tinnitus has not yet been examined. The present study (a) explores latent dimensions of psychological distress in a sample of chronic tinnitus patients, and (b) examines whether the schema mode model might explain these dimensions - thus constituting a potentially helpful conceptualization and treatment framework.

Methods

N = 696 patients with chronic tinnitus completed the Tinnitus Questionnaire, Tinnitus Handicap Inventory, Hospital Anxiety and Depression Scale, Perceived Stress Questionnaire and ICD-10 Symptom Rating. As criterion, patients further completed the Schema Mode Inventory (SMI-r) - which assesses psychological constructs linked to negative self-beliefs ("parent modes"), primary emotions resulting from unmet psychological needs ("child modes"), and secondary emotional or behavioral attempts to reinstate or maintain psychological equilibrium ("coping modes"). A varimax-rotated principal axis factor analysis grouped the primary item pool. Factor scale scores were then correlated with the SMI-r.

Results

A three-factor solution explained 37.4% of variance and represented 78% of the included items. Following item content examination, the factors represented (1) General emotional distress, (2) Tinnitus-attributed emotional distress, and (3) Socio-audiological impairment. Factors 1|2 correlated highly (r = 0.70), Factors 2|3 moderately (r = 0.62). Linked to the schema mode model, Factor 1 correlated highly with the "vulnerable child" (r = 0.78), and moderately with the "parent", "angry child", and "detached protector" modes (0.53 < r < 0.65). Factor 2 correlated moderately with the "vulnerable child" (r = 0.53). Factor 3 was largely uncorrelated with SMI-r scores - although a low correlation with the "detached protector" warrants further examination.

Conclusion

"General" and "tinnitus-attributed" emotional distress correlate highly - warranting holistic (not symptom-specific) psychological case conceptualization and treatment planning. Viewed from a schema mode perspective, the "vulnerable child" explains substantial variance across both dimensions. Consequently, autobiographically anchored, unmet emotional needs and emotional detachment constitute key treatment targets. Social-audiological impairment should be multimodally conceptualised and treated with hearing aids and psychological support measures, as applicable.

Emotion dynamics and somatic symptoms in everyday life: Ecological momentary assessment in somatic symptom disorder and healthy controls

OBJECTIVE

Negative affectivity (NA) is associated with the emergence and persistence of physical symptoms with unclear organic pathology. This study investigated the temporal dynamics of NA and somatic symptom burden using ecological momentary assessment (EMA) in adults with somatic symptom disorder (SSD) and healthy control participants (HC).

METHODS

Participants underwent a seven-day, smartphone-based EMA, with 6 randomly-stratified time points per day. NA was assessed using a five-item short form of the Positive and Negative Affectivity Scale (PANAS) and somatic symptom burden with two self-constructed items. 22 persons with SSD and 20 HCs were included in multilevel analyses.

RESULTS

Within-person analyses showed a significantly stronger (positive) association of concurrent NA with somatic symptom burden in participants with SSD than in HCs, β = 0.15, SE = 0.04, p = .001. Time-lagged analyses demonstrated that, across groups, NA at a previous time point t-1 significantly predicted somatic symptom burden at the subsequent timepoint t, β = 0.09, SE = 0.03, p = .005, but not in the other direction (somatic symptom burdent-1→ NAt, β = 0.01, SE = 0.04, p = .79). Between-person analyses showed that both inertia (i.e., persistence of negative affective states), d = 0.74, and instability (i.e., magnitude of moment-to-moment fluctuations), d = 0.76 of NA were significantly higher in participants with SSD than in HCs.

CONCLUSIONS

Our findings sustain the idea of (negative) affect-driven modulation in somatic signal processing and suggest that interoceptive and emotional differentiation training can advance the psychotherapeutic treatment of SSD.

The association between stress, emotional states, and tinnitus: a mini-review

Extensive literature supporting the view of tinnitus induced stress in patients is available. However, limited evidence has been produced studying the opposite, that is, does stress cause tinnitus? The hypothalamus pituitary adrenal axis, one of the main neuroendocrine systems involved in stress response, is commonly disturbed in tinnitus patients. Patients with chronic tinnitus have been shown to develop abnormal responses to psycho-social stress, where the hypothalamus pituitary adrenal axis response is weaker and delayed, suggesting chronic stress contributes to the development of chronic tinnitus. The sympathetic branch of the autonomic nervous system also plays a major role in stress response and its chronic hyperactivity seems to be involved in developing tinnitus. Psycho-social stress has been shown to share the same probability of developing tinnitus as occupational noise and contributes to worsening tinnitus. Additionally, exposure to high stress levels and occupational noise doubles the likelihood of developing tinnitus. Interestingly, short-term stress has been shown to protect the cochlea in animals, but chronic stress exposure has negative consequences. Emotional stress also worsens pre-existing tinnitus and is identified as an important indicator of tinnitus severity. Although there is limited body of literature, stress does seem to play a vital role in the development of tinnitus. This review aims to highlight the association between stress, emotional states, and the development of tinnitus while also addressing the neural and hormonal pathways involved.

Hearing Aid Use Time Is Causally Influenced by Psychological Parameters in Mildly Distressed Patients with Chronic Tinnitus and Mild-to-Moderate Hearing Loss

Background: Hearing aids (HAs) can improve tinnitus-related distress (TRD) and speech-comprehension (SC) in silence or at 55 dB level of noise-interference (SC_55 dB) in patients with chronic tinnitus and mild-to-moderate hearing loss. However, the role of HA use time in relation to psychological, audiological, or self-reported tinnitus characteristics is an under-investigated area. Methods: We examine 177 gender-stratified patients before (t1) and after an intervention comprising binaural DSLchild algorithm-based HA fitting and auditory training (t2) and at a 70-day follow up [t3]. HA use time was retrospectively retrieved (at t2) for the pre-post- and (at t3) post-follow up periods. General linear models investigated HA use time in relation to (1) general audiological, (2) tinnitus-related audiological, (3) tinnitus-related self-report, and (4) distress-related self-report indices before and after treatment, where applicable. Receiver operator characteristic analyses identified optimal HA use time for hereby-mediated treatment changes. Results: At t1 and t2, psychological, but not audiological indices causally influenced prospective HA use time—except for SC_55 dB at t1, which, however, correlated with patients’ anxiety, depressivity, and psychological distress levels. Correlations did not differ between patient subgroups defined by categorical tinnitus-related audiological or self-report indices. HA use time partly mediated treatment-related improvement in TRD, but not SC. Optimal use amounted to 9.5–10.5 h/day. Conclusions: An awareness of psychological influences may help clinicians facilitate HA use and, thereby, TRD improvement with hearing amplification.

A gentle tutorial on accelerated parameter and confidence interval estimation for hidden Markov models using Template Model Builder

A very common way to estimate the parameters of a hidden Markov model (HMM) is the relatively straightforward computation of maximum likelihood (ML) estimates. For this task, most users rely on user-friendly implementation of the estimation routines via an interpreted programming language such as the statistical software environment R. Such an approach can easily require time-consuming computations, in particular for longer sequences of observations. In addition, selecting a suitable approach for deriving confidence intervals for the estimated parameters is not entirely obvious, and often the computationally intensive bootstrap methods have to be applied. In this tutorial, we illustrate how to speed up the computation of ML estimates significantly via the R package TMB. Moreover, this approach permits simple retrieval of standard errors at the same time. We illustrate the performance of our routines using different data sets: first, two smaller samples from a mobile application for tinnitus patients and a well-known data set of fetal lamb movements with 87 and 240 data points, respectively. Second, we rely on larger data sets of simulated data of sizes 2000 and 5000 for further analysis. This tutorial is accompanied by a collection of scripts, which are all available in the Supporting Information. These scripts allow any user with moderate programming experience to benefit quickly from the computational advantages of TMB.

A device and an app for the diagnosis and self-management of tinnitus

Tinnitus is an annoying ringing in the ears, in varying shades and intensities. Tinnitus can affect a person’s overall health and social well-being (e.g., sleep problems, trouble concentrating, anxiety, depression and inability to work). The diagnostic procedure of tinnitus usually consists of three steps: an audiological examination, psychoacoustic measurement, and a disability evaluation. All steps are performed by physicians, who use specialised hardware/software and administer questionnaires. This paper presents a system, to be used by patients, for the diagnosis and self-management of tinnitus. The system is made up of an app and a device. The app is responsible for executing – through the device – a part of the required audiological and psychoacoustic examinations, as well as administering questionnaires that evaluate disability. The paper reviews the quality of the automated audiometric reporting and the user experience provided by the app. Descriptive and inferential statistics were used to support the findings. The results show that automated reporting is comparable with that of physicians and that user experience was improved by re-designing and re-developing the acufenometry of the app. As for the user experience, two experts in Human-Computer Interaction evaluated the first version of the app: their agreement was good (Cohen’s K = 0.639) and the average rating of the app was 1.43/2. Also patients evaluated the app in its initial version: the satisfactory tasks (audiometry and questionnaires) were rated as 4.31/5 and 4.65/5. The unsatisfactory task (acufenometry) was improved and the average rating increased from 2.86/5 to 3.96/5 (p = 0.0005). Finally, the general usability of the app was increased from the initial value of 73.6/100 to 85.4/100 (p = 0.0003). The strengths of the project are twofold. Firstly, the automated reporting feature, which – to the best of our knowledge – is the first attempt in this area. Secondly, the overall app usability, which was evaluated and improved during its development. In summary, the conclusion drawn from the conducted project is that the system works as expected, and despite some weaknesses, also the replication of the device would not be expensive, and it can be used in different scenarios.

The Fudan Tinnitus Relieving System (FTRS): The initial results of a smartphone application for tinnitus management and treatment

OBJECTIVE

Tinnitus is highly prevalent in the population, but there are currently few effective therapeutic interventions. Mobile applications (apps) might be helpful in tinnitus diagnosis and treatment by offering sound or music tools as well as questionnaires. We assessed the efficacy of a free, publicly available smartphone app (Fudan Tinnitus Relieving System, FTRS) for self-management of tinnitus and related symptoms.

METHODS

Among a total of 3564 participants recruited primarily online, 2744 patients had complete information at baseline and were an average of 37 years old and were 59.84 % male. Web-administered self-report measures THI, HADS, AIS, and other multi-dimensional scales were conducted at baseline and at 1 month and 2 months following treatment. Data from 54 participants who completed continuous follow-up were used for the final efficacy analysis and longitudinal analysis.

RESULTS

Following the intent-to-treat principle, t-tests revealed that the distribution of patients and the tinnitus features of patients of different genders were heterogeneous. One-way ANOVA showed that after using the FTRS app, THI scores showed a decreasing trend (p < 0.001).

CONCLUSION

FTRS use resulted in significantly greater improvements in tinnitus and other outcomes relative to their baseline condition before treatment. Given the ubiquity of smartphones, FTRS may provide a wide-reaching and convenient public health intervention for individuals with tinnitus symptoms.

The Language of the Times: Using the COVID-19 Pandemic to Assess the Influence of News Affect on Online Mental Health-Related Search Behavior across the United States

Background

The digital era has ushered in an unprecedented volume of readily accessible information, including news coverage of current events. Research has shown that the sentiment of news articles can evoke emotional responses from readers on a daily basis with specific evidence for increased anxiety and depression in response to coverage of the recent COVID-19 pandemic. Given the primacy and relevance of such information exposure, its daily impact on the mental health of the general population within this modality warrants further nuanced investigation.

Objective

Using the COVID-19 pandemic as a subject-specific example, this work aimed to profile and examine associations between the dynamics of semantic affect in online local news headlines and same-day online mental health term search behavior over time across the United States.

Methods

Using COVID-19–related news headlines from a database of online news stories in conjunction with mental health–related online search data from Google Trends, this paper first explored the statistical and qualitative affective properties of state-specific COVID-19 news coverage across the United States from January 23, 2020, to October 22, 2020. The resultant operationalizations and findings from the joint application of dictionary-based sentiment analysis and the circumplex theory of affect informed the construction of subsequent hypothesis-driven mixed effects models. Daily state-specific counts of mental health search queries were regressed on circumplex-derived features of semantic affect, time, and state (as a random effect) to model the associations between the dynamics of news affect and search behavior throughout the pandemic. Search terms were also grouped into depression symptoms, anxiety symptoms, and nonspecific depression and anxiety symptoms to model the broad impact of news coverage on mental health.

Results

Exploratory efforts revealed patterns in day-to-day news headline affect variation across the first 9 months of the pandemic. In addition, circumplex mapping of the most frequently used words in state-specific headlines uncovered time-agnostic similarities and differences across the United States, including the ubiquitous use of negatively valenced and strongly arousing language. Subsequent mixed effects modeling implicated increased consistency in affective tone (Spin_VA β=–.207; P<.001) as predictive of increased depression-related search term activity, with emotional language patterns indicative of affective uncontrollability (Flux_A β=.221; P<.001) contributing generally to an increase in online mental health search term frequency.

Conclusions

This study demonstrated promise in applying the circumplex model of affect to written content and provided a practical example for how circumplex theory can be integrated with sentiment analysis techniques to interrogate mental health–related associations. The findings from pandemic-specific news headlines highlighted arousal, flux, and spin as potentially significant affect-based foci for further study. Future efforts may also benefit from more expansive sentiment analysis approaches to more broadly test the practical application and theoretical capabilities of the circumplex model of affect on text-based data.

Auricular Acupressure Combined with Self-Help Intervention for Treating Chronic Tinnitus: A Longitudinal Observational Study

Tinnitus is a phantom sound perception in the ears or head and can arise from many different medical disorders. Currently, there is no standard treatment for tinnitus that reliably reduces tinnitus. Individual patients reported that acupressure at various points around the ear can help to reduce tinnitus, which was investigated here. With this longitudinal observational study, we report a systematic evaluation of auricular acupressure on 39 tinnitus sufferers, combined with a self-help smartphone app. The participants were asked to report on tinnitus, stress, mood, neck, and jaw muscle tensions twice a day using an ecological momentary assessment study design for six weeks. On average, 123.6 questionnaires per person were provided and used for statistical analysis. The treatment responses of the participants were heterogeneous. On average, we observed significant negative trends for tinnitus loudness (Cohen’s d effect size: −0.861), tinnitus distress (d = −0.478), stress (d = −0.675), and tensions in the neck muscles (d = −0.356). Comparison with a matched control group revealed significant improvements for tinnitus loudness (p = 0.027) and self-reported stress level (p = 0.003). The positive results of the observational study motivate further research including a randomized clinical trial and long-term assessment of the clinical improvement.

Psychological Comorbidities of Tinnitus

In this chapter, I address the topic of tinnitus in the context of the patient's trajectory of care, with special attention to psychological comorbidities. Although most patients will cope with tinnitus and need no more than information and reassurance from professionals, a proportion of patients will need more supportive management. Assessment of psychological comorbidities is important to determine how urgent they should be seen in the clinic and their specific needs. The most frequent complaints are stress, depression, and anxiety. Although the direction of this relationship is still unclear (are comorbidities at the origin of tinnitus or are they a consequence of it), it is evident that the more serious comorbidities are at the onset of tinnitus, the worse the prognosis. Therefore, an assessment at the initial visit in the clinic is of utmost importance. There are valid and reliable psychometric tools to quickly draw a portrait of the psychological state of patients that can be used by audiologists, psychologists, or doctors. Therapeutic avenues can then be discussed with the patients to ensure them the best support possible.

COVID-19 associated anxiety enhances tinnitus

To investigate if the anxiety associated with coronavirus disease 2019 (COVID-19) is a promoting factor to tinnitus. A retrospective research design collected from 188 tinnitus patients, was used to compare the clinical characteristics of tinnitus between the patients in 2020 under pandemic pressure and those from the matching period in 2019. While anxiety was quantified using the Zung's Self-rating Anxiety Scale (SAS), tinnitus severity was evaluated using the Tinnitus Handicap Inventory (THI) questionnaire and the test of tinnitus loudness (TL). The assessments were repeated after the sound therapy plus educational counselling (STEC) for 38 patients in 2020 and 58 patients in 2019 and compared with EC alone therapy for 42 patients in 2020 and 17 patients in 2019. A large increase in anxiety was evident in 2020 in both case rate and SAS. The treatment of both methods was less effective in 2020. SAS, THI and TL were all deteriorated after the EC alone treatment in 2020, while an improvement was seen in 2019. This suggests that EC alone could not counteract the stress by COVID-19 at all, and the stress, if not managed well, can significantly increase the severity of tinnitus and associated anxiety. By using the EC subgroup in virtual control, we conclude that anxiety can serve as a promoting factor to tinnitus. We believe that this is the first study report that confirm the causative/promotive role of anxiety on tinnitus during COVID-19 pandemic.

Understanding adherence to the recording of ecological momentary assessments in the example of tinnitus monitoring

The recording of Ecological Momentary Assessments (EMA) can assist people with chronic diseases in monitoring their health state. However, many users quickly lose interest in their respective EMA platforms. Therefore, we studied the adherence of users of the mHealth app TrackYourTinnitus (TYT). The app is used to record EMA in people with tinnitus. 1292 users, who interacted with the app between April 2014 and February 2017, were analyzed in this work. We defined “adherence” based on the dimensions of interaction duration and interaction continuity. We propose methods that are able to predict the (dis)continuation of interaction with the app and identify user segments that are characterized by similar patterns of adherence. For the prediction task we used the data of the questionnaires MiniTF and TSCHQ, which are filled in when the users enter TYT for the first time. Additionally, time series of the eight items of the daily EMA questionnaire were used. The distribution of user activity pertaining to the adherence dimension of interaction duration revealed a very skewed distribution, with most users giving up after only 1 day of interaction. However, many users returned after interrupting for some time. Some of the MiniTF items indicated that the worries of users might have lead to an increased likelihood of returning back to the app. The MiniTF score itself was not predictive, though. The answers to the TSCHQ items, in turn, pointed to user strata (more than 65 years of age at registration), which tended towards higher interaction continuity. As the registration questionnaires predicted adherence only to a limited extent, it is promising to study the activities of the users in the very first days of interaction more deeply. It turned out in this context that the effects of interaction stimulants like personalized and non-personalized tips, pointers to information sources, and mechanisms used in online treatments for tinnitus (e.g., in iCBT) should be further investigated.

Contemporary Review of Smartphone Apps for Tinnitus Management and Treatment

Tinnitus is a complex and heterogeneous psycho-physiological disorder responsible for causing a phantom ringing or buzzing sound albeit the absence of an external sound source. It has a direct influence on affecting the quality of life of its sufferers. Despite being around for a while, there has not been a cure for tinnitus, and the usual course of action for its treatment involves use of tinnitus retaining and sound therapy, or Cognitive Behavioral Therapy (CBT). One positive aspect about these therapies is that they can be administered face-to-face as well as delivered via internet or smartphone. Smartphones are especially helpful as they are highly personalized devices, and offer a well-established ecosystem of apps, accessible via respective marketplaces of differing mobile platforms. Note that current therapeutic treatments such as CBT have shown to be effective in suppressing the tinnitus symptoms when administered face-to-face, their effectiveness when being delivered using smartphones is not known so far. A quick search on the prominent market places of popular mobile platforms (Android and iOS) yielded roughly 250 smartphone apps offering tinnitus-related therapies and tinnitus management. As this number is expected to steadily increase due to high interest in smartphone app development, a contemporary review of such apps is crucial. In this paper, we aim to review scientific studies validating the smartphone apps, particularly to test their effectiveness in tinnitus management and treatment. We use the PRISMA guidelines for identification of studies on major scientific literature sources and delineate the outcomes of identified studies.

Comparing Three Established Methods for Tinnitus Pitch Matching With Respect to Reliability, Matching Duration, and Subjective Satisfaction

The pitch of tinnitus sound is a key characteristic that is of importance to research and sound therapies relying on exact tinnitus pitch matches. The identification of this tinnitus pitch is a challenging task as there is no objective measurement available. During the tinnitus pitch-matching procedure, the participant identifies an external sound that is most similar to the subjective perception of the tinnitus. Several methods have been developed to perform this pitch-matching procedure with tinnitus sufferers. In this study, we aimed to compare the method of adjustment, the two-alternative forced-choice (2AFC) method, and the likeness rating (LR) with respect to reliability, matching duration, and subjective satisfaction. Fifty-nine participants with chronic tinnitus were recruited and performed five consecutive runs of tinnitus matching. The participants were randomized to the three different pitch-matching methods. The intraclass correlation coefficients were .67 for method of adjustment, .63 for 2AFC, and .69 for LR, which can be interpreted as good reliability for all the three methods. However, the 2AFC method revealed significant larger within-subject variability than the other measures. Across the five runs and the three different methods, all participants learned to perform the pitch matching faster and with better self-rated accuracy. Comparing the three pitch-matching methods, LR is more time consuming and the participants were less satisfied with the 2AFC method. Overall, the three pitch-matching methods show good reliability. However, we identified differential aspects for improvement in all methods, which are discussed in this article.

The Effect of Environmental Stressors on Tinnitus: A Prospective Longitudinal Study on the Impact of the COVID-19 Pandemic

Tinnitus, the perception of sound in the absence of a corresponding sound, and the distress caused by it, is rarely a static phenomenon. It rather fluctuates over time depending on endogenous and exogenous factors. The COVID-19 pandemic is a potential environmental stressor that might influence the individually perceived tinnitus distress. Since not all people are affected by the pandemic in the same way, the situation allows one to identify environmental factors and personality traits that impact tinnitus distress differently. In our study, 122 tinnitus patients were included at two time points: in the year 2018 and during the German lockdown in April 2020. We assessed tinnitus-related distress, depressive symptoms, personality characteristics and the individual perception of the pandemic situation. On average, there was only a small increase of tinnitus distress with heterogeneous changes during the lockdown. People perceiving the situation as generally stressful with increased grief, frustration, stress and nervousness reported the worsening of tinnitus distress. People with high values in neuroticism also reported the worsening of tinnitus distress, while the personality traits extraversion, conscientiousness and openness seemed to be a protection factor. The study identifies factors that influence tinnitus distress change during a pandemic and spots those patients that need specific help in the pandemic situation.

The Bayesian brain in imbalance: Medial, lateral and descending pathways in tinnitus and pain: A perspective

Tinnitus and pain share similarities in their anatomy, pathophysiology, clinical picture and treatments. Based on what is known in the pain field, a heuristic model can be proposed for the pathophysiolgy of tinnitus. This heuristic pathophysiological model suggests that pain and tinnitus are the consequence of an imbalance between two pain/tinnitus evoking pathways, i.e., a lateral sensory pathway and a medial affective pathway, both of which are not balanced anymore by a pain/noise inhibitory pathway. Mechanistically, based on the Bayesian brain concept, it can be explained by a switch occuring under influence of the rostral to dorsal anterior cingulate cortex of its prior predictions, i.e., a reference resetting, in which the pain/tinnitus state is considered as the new reference state. This reference resetting is confirmed by the nucleus accumbens as part of the reward system and maintained by connectivity changes between the nucleus accumbens and the pregenual anterior cingulate cortex. As a consequence it can be suggested to treat pain/tinnitus via reconditioning, either surgically or non-surgically. The model can also be used to develop objective measures for tinnitus and pain via supervised machine learning.

Smartphone and Mobile Health Apps for Tinnitus: Systematic Identification, Analysis, and Assessment

Background

Modern smartphones contain sophisticated high-end hardware features, offering high computational capabilities at extremely manageable costs and have undoubtedly become an integral part in users' daily life. Additionally, smartphones offer a well-established ecosystem that is easily discoverable and accessible via the marketplaces of differing mobile platforms, thus encouraging the development of many smartphone apps. Such apps are not exclusively used for entertainment purposes but are also commonplace in health care and medical use. A variety of those health and medical apps exist within the context of tinnitus, a phantom sound perception in the absence of any physical external source.

Objective

In this paper, we shed light on existing smartphone apps addressing tinnitus by providing an up-to-date overview.

Methods

Based on PRISMA guidelines, we systematically searched and identified existing smartphone apps on the most prominent app markets, namely Google Play Store and Apple App Store. In addition, we applied the Mobile App Rating Scale (MARS) to evaluate and assess the apps in terms of their general quality and in-depth user experience.

Results

Our systematic search and screening of smartphone apps yielded a total of 34 apps (34 Android apps, 26 iOS apps). The mean MARS scores (out of 5) ranged between 2.65-4.60. The Tinnitus Peace smartphone app had the lowest score (mean 2.65, SD 0.20), and Sanvello—Stress and Anxiety Help had the highest MARS score (mean 4.60, SD 0.10). The interrater agreement was substantial (Fleiss κ=0.74), the internal consistency was excellent (Cronbach α=.95), and the interrater reliability was found to be both high and excellent—Guttman λ6=0.94 and intraclass correlation, ICC(2,k) 0.94 (95% CI 0.91-0.97), respectively.

Conclusions

This work demonstrated that there exists a plethora of smartphone apps for tinnitus. All of the apps received MARS scores higher than 2, suggesting that they all have some technical functional value. However, nearly all identified apps were lacking in terms of scientific evidence, suggesting the need for stringent clinical validation of smartphone apps in future. To the best of our knowledge, this work is the first to systematically identify and evaluate smartphone apps within the context of tinnitus.

Applying Machine Learning to Daily-Life Data From the TrackYourTinnitus Mobile Health Crowdsensing Platform to Predict the Mobile Operating System Used With High Accuracy: Longitudinal Observational Study

BACKGROUND

Tinnitus is often described as the phantom perception of a sound and is experienced by 5.1% to 42.7% of the population worldwide, at least once during their lifetime. The symptoms often reduce the patient's quality of life. The TrackYourTinnitus (TYT) mobile health (mHealth) crowdsensing platform was developed for two operating systems (OS)-Android and iOS-to help patients demystify the daily moment-to-moment variations of their tinnitus symptoms. In all platforms developed for more than one OS, it is important to investigate whether the crowdsensed data predicts the OS that was used in order to understand the degree to which the OS is a confounder that is necessary to consider.

OBJECTIVE

In this study, we explored whether the mobile OS-Android and iOS-used during user assessments can be predicted by the dynamic daily-life TYT data.

METHODS

TYT mainly applies the paradigms ecological momentary assessment (EMA) and mobile crowdsensing to collect dynamic EMA (EMA-D) daily-life data. The dynamic daily-life TYT data that were analyzed included eight questions as part of the EMA-D questionnaire. In this study, 518 TYT users were analyzed, who each completed at least 11 EMA-D questionnaires. Out of these, 221 were iOS users and 297 were Android users. The iOS users completed, in total, 14,708 EMA-D questionnaires; the number of EMA-D questionnaires completed by the Android users was randomly reduced to the same number to properly address the research question of the study. Machine learning methods-a feedforward neural network, a decision tree, a random forest classifier, and a support vector machine-were applied to address the research question.

RESULTS

Machine learning was able to predict the mobile OS used with an accuracy up to 78.94% based on the provided EMA-D questionnaires on the assessment level. In this context, the daily measurements regarding how users concentrate on the actual activity were particularly suitable for the prediction of the mobile OS used.

CONCLUSIONS

In the work at hand, two particular aspects have been revealed. First, machine learning can contribute to EMA-D data in the medical context. Second, based on the EMA-D data of TYT, we found that the accuracy in predicting the mobile OS used has several implications. Particularly, in clinical studies using mobile devices, the OS should be assessed as a covariate, as it might be a confounder.

Ecological Momentary Assessment based Differences between Android and iOS Users of the TrackYourHearing mHealth Crowdsensing Platform

mHealth technologies are increasingly utilized in various medical contexts. Mobile crowdsensing is such a technology, which is often used for data collection scenarios related to questions on chronic disorders. One prominent reason for the latter setting is based on the fact that powerful Ecological Momentary Assessments (EMA) can be performed. Notably, when mobile crowdsensing solutions are used to integrate EMA measurements, many new challenges arise. For example, the measurements must be provided in the same way on different mobile operating systems. However, the newly given possibilities can surpass the challenges. For example, if different mobile operating systems must be technically provided, one direction could be to investigate whether users of different mobile operating systems pose a different behaviour when performing EMA measurements. In a previous work, we investigated differences between iOS and Android users from the TrackYourTinnitus mHealth crowdsensing platform, which has the goal to reveal insights on the daily fluctuations of tinnitus patients. In this work, we investigated differences between iOS and Android users from the TrackYourHearing mHealth crowdsensing platform, which aims at insights on the daily fluctuations of patients with hearing loss. We analyzed 3767 EMA measurements based on a daily applied questionnaire of 84 patients. Statistical analyses have been conducted to see whether these 84 patients differ with respect to the used mobile operating system and their given answers to the EMA measurements. We present the obtained results and compare them to the previous mentioned study. Our insights show the differences in the two studies and that the overall results are worth being investigated in a more in-depth manner. Particularly, it must be investigated whether the used mobile operating system constitutes a confounder when gathering EMA-based data through a crowdsensing platform.

Smartphone Apps in the Context of Tinnitus: Systematic Review

Smartphones containing sophisticated high-end hardware and offering high computational capabilities at extremely manageable costs have become mainstream and an integral part of users' lives. Widespread adoption of smartphone devices has encouraged the development of many smartphone applications, resulting in a well-established ecosystem, which is easily discoverable and accessible via respective marketplaces of differing mobile platforms. These smartphone applications are no longer exclusively limited to entertainment purposes but are increasingly established in the scientific and medical field. In the context of tinnitus, the ringing in the ear, these smartphone apps range from relief, management, self-help, all the way to interfacing external sensors to better understand the phenomenon. In this paper, we aim to bring forth the smartphone applications in and around tinnitus. Based on the PRISMA guidelines, we systematically analyze and investigate the current state of smartphone apps, that are directly applied in the context of tinnitus. In particular, we explore Google Scholar, CiteSeerX, Microsoft Academics, Semantic Scholar for the identification of scientific contributions. Additionally, we search and explore Google's Play and Apple's App Stores to identify relevant smartphone apps and their respective properties. This review work gives (1) an up-to-date overview of existing apps, and (2) lists and discusses scientific literature pertaining to the smartphone apps used within the context of tinnitus.

Measuring Mental Effort for Creating Mobile Data Collection Applications

To deal with drawbacks of paper-based data collection procedures, the QuestionSys approach empowers researchers with none or little programming knowledge to flexibly configure mobile data collection applications on demand. The mobile application approach of QuestionSys mainly pursues the goal to mitigate existing drawbacks of paper-based collection procedures in mHealth scenarios. Importantly, researchers shall be enabled to gather data in an efficient way. To evaluate the applicability of QuestionSys, several studies have been carried out to measure the efforts when using the framework in practice. In this work, the results of a study that investigated psychological insights on the required mental effort to configure the mobile applications are presented. Specifically, the mental effort for creating data collection instruments is validated in a study with N = 80 participants across two sessions. Thereby, participants were categorized into novices and experts based on prior knowledge on process modeling, which is a fundamental pillar of the developed approach. Each participant modeled 10 instruments during the course of the study, while concurrently several performance measures are assessed (e.g., time needed or errors). The results of these measures are then compared to the self-reported mental effort with respect to the tasks that had to be modeled. On one hand, the obtained results reveal a strong correlation between mental effort and performance measures. On the other, the self-reported mental effort decreased significantly over the course of the study, and therefore had a positive impact on measured performance metrics. Altogether, this study indicates that novices with no prior knowledge gain enough experience over the short amount of time to successfully model data collection instruments on their own. Therefore, QuestionSys is a helpful instrument to properly deal with large-scale data collection scenarios like clinical trials.

Apps for Hearing Healthcare

This chapter provides a picture of the evolution of mobile applications (apps) for hearing health care (HHC) in terms of availability, variety, penetration, offered services, and target users. Special emphasis is given to newly developed methods that might assist audiologists and hearing professionals to get meaningful information and guidance for informed adoption of apps for themselves as well as for patients and their families. The chapter also shows how these novel methods can be used to characterize and compare a variety of apps across a wide range of services and target user groups. A representative sample of apps, assessed by using such a standardized framework, is analyzed to derive a multifaceted picture of apps for HHC. The chapter outlines and discusses emerging trends and needs in the area and highlights the open challenges as well as potential opportunities for professionals, researchers, developers, and stakeholders at large.

The minute-scale dynamics of online emotions reveal the effects of affect labeling

Putting one's feelings into words (also called affect labeling) can attenuate positive and negative emotions. Here, we track the evolution of specific emotions for 74,487 Twitter users by analysing the emotional content of their tweets before and after they explicitly report experiencing a positive or negative emotion. Our results describe the evolution of emotions and their expression at the temporal resolution of one minute. The expression of positive emotions is preceded by a short, steep increase in positive valence and followed by short decay to normal levels. Negative emotions, however, build up more slowly and are followed by a sharp reversal to previous levels, consistent with previous studies demonstrating the attenuating effects of affect labeling. We estimate that positive and negative emotions last approximately 1.25 and 1.5 h, respectively, from onset to evanescence. A separate analysis for male and female individuals suggests the potential for gender-specific differences in emotional dynamics.

Functional brain changes in auditory phantom perception evoked by different stimulus frequencies

Bayesian models of brain function such as active inference and predictive coding offer a general theoretical framework with which to explain several aspects of normal and disordered brain function. Of particular interest to the present study is the potential for such models to explain the pathology of auditory phantom perception, i.e. tinnitus. To test this framework empirically, we perform an fMRI experiment on a large clinical sample (n = 75) of the human chronic tinnitus population. The experiment features a within-subject design based on two experimental conditions: subjects were presented with sound stimuli matched to their tinnitus frequency (TF) as well as similar stimuli presented at a control frequency (CF). The responses elicited by these stimuli, as measured using both activity and functional connectivity, were then analyzed both within and between conditions. Given the Bayesian-brain framework, we hypothesize that TF stimuli will elicit greater activity and/or functional connectivity in areas related to the cognitive and emotional aspects of tinnitus, i.e. tinnitus-related distress. We conversely hypothesize that CF stimuli will elicit greater activity/connectivity in areas related to auditory perception and attention. We discuss our results in the context of this framework and suggest future directions for empirical testing.

Review of Smart Services for Tinnitus Self-Help, Diagnostics and Treatments

In the recent years, there has been an increasing interest in the potential of internet- and smartphone-based technologies for the support of tinnitus patients. A broad spectrum of relevant approaches, some in the form of studies, others in the form of market products, have been mentioned in literature. They include auditory treatments, internet-based Cognitive Behavioral Therapy (iCBT), serious games, and questionnaires for tinnitus monitoring. The goal of this study is to highlight the role of existing internet-based and smart technologies for the advancement of tinnitus clinical practice: we consider contributions that refer to treatments and diagnostics, and we include contributions refering to self-help measures. We elaborate on the potential and challenges of such solutions and identify constraints associated to their deployment, such as the demand for familiarity with internet-based services and the need to re-design interactive services so that they fit on the small surface of a smartwatch.

Learnability of a Configurator Empowering End Users to Create Mobile Data Collection Instruments: Usability Study

BACKGROUND

Many research domains still heavily rely on paper-based data collection procedures, despite numerous associated drawbacks. The QuestionSys framework is intended to empower researchers as well as clinicians without programming skills to develop their own smart mobile apps in order to collect data for their specific scenarios.

OBJECTIVE

In order to validate the feasibility of this model-driven, end-user programming approach, we conducted a study with 80 participants.

METHODS

Across 2 sessions (7 days between Session 1 and Session 2), participants had to model 10 data collection instruments (5 at each session) with the developed configurator component of the framework. In this context, performance measures like the time and operations needed as well as the resulting errors were evaluated. Participants were separated into two groups (ie, novices vs experts) based on prior knowledge in process modeling, which is one fundamental pillar of the QuestionSys framework.

RESULTS

Statistical analysis (t tests) revealed that novices showed significant learning effects for errors (P=.04), operations (P<.001), and time (P<.001) from the first to the last use of the configurator. Experts showed significant learning effects for operations (P=.001) and time (P<.001), but not for errors as the experts' errors were already very low at the first modeling of the data collection instrument. Moreover, regarding the time and operations needed, novices got significantly better at the third modeling task than experts were at the first one (t tests; P<.001 for time and P=.002 for operations). Regarding errors, novices did not get significantly better at working with any of the 10 data collection instruments than experts were at the first modeling task, but novices' error rates for all 5 data collection instruments at Session 2 were not significantly different anymore from those of experts at the first modeling task. After 7 days of not using the configurator (from Session 1 to Session 2), the experts' learning effect at the end of Session 1 remained stable at the beginning of Session 2, but the novices' learning effect at the end of Session 1 showed a significant decay at the beginning of Session 2 regarding time and operations (t tests; P<.001 for time and P=.03 for operations).

CONCLUSIONS

In conclusion, novices were able to use the configurator properly and showed fast (but unstable) learning effects, resulting in their performances becoming as good as those of experts (which were already good) after having little experience with the configurator. Following this, researchers and clinicians can use the QuestionSys configurator to develop data collection apps for smart mobile devices on their own.

Does Tinnitus Depend on Time-of-Day? An Ecological Momentary Assessment Study with the "TrackYourTinnitus" Application

Only few previous studies used ecological momentary assessments to explore the time-of-day-dependence of tinnitus. The present study used data from the mobile application “TrackYourTinnitus” to explore whether tinnitus loudness and tinnitus distress fluctuate within a 24-h interval. Multilevel models were performed to account for the nested structure of assessments (level 1: 17,209 daily life assessments) nested within days (level 2: 3,570 days with at least three completed assessments), and days nested within participants (level 3: 350 participants). Results revealed a time-of-day-dependence of tinnitus. In particular, tinnitus was perceived as louder and more distressing during the night and early morning hours (from 12 a.m. to 8 a.m.) than during the upcoming day. Since previous studies suggested that stress (and stress-associated hormones) show a circadian rhythm and this might influence the time-of-day-dependence of tinnitus, we evaluated whether the described results change when statistically controlling for subjectively reported stress-levels. Correcting for subjective stress-levels, however, did not change the result that tinnitus (loudness and distress) was most severe at night and early morning. These results show that time-of-day contributes to the level of both tinnitus loudness and tinnitus distress. Possible implications of our results for the clinical management of tinnitus are that tailoring the timing of therapeutic interventions to the circadian rhythm of individual patients (chronotherapy) might be promising.

Visualization of Global Disease Burden for the Optimization of Patient Management and Treatment

Background

The assessment and treatment of complex disorders is challenged by the multiple domains and instruments used to evaluate clinical outcome. With the large number of assessment tools typically used in complex disorders comes the challenge of obtaining an integrative view of disease status to further evaluate treatment outcome both at the individual level and at the group level. Radar plots appear as an attractive visual tool to display multivariate data on a two-dimensional graphical illustration. Here, we describe the use of radar plots for the visualization of disease characteristics applied in the context of tinnitus, a complex and heterogeneous condition, the treatment of which has shown mixed success.

Methods

Data from two different cohorts, the Swedish Tinnitus Outreach Project (STOP) and the Tinnitus Research Initiative (TRI) database, were used. STOP is a population-based cohort where cross-sectional data from 1,223 non-tinnitus and 933 tinnitus subjects were analyzed. By contrast, the TRI contained data from 571 patients who underwent various treatments and whose Clinical Global Impression (CGI) score was accessible to infer treatment outcome. In the latter, 34,560 permutations were tested to evaluate whether a particular ordering of the instruments could reflect better the treatment outcome measured with the CGI.

Results

Radar plots confirmed that tinnitus subtypes such as occasional and chronic tinnitus from the STOP cohort could be strikingly different, and helped appreciate a gender bias in tinnitus severity. Radar plots with greater surface areas were consistent with greater burden, and enabled a rapid appreciation of the global distress associated with tinnitus in patients categorized according to tinnitus severity. Permutations in the arrangement of instruments allowed to identify a configuration with minimal variance and maximized surface difference between CGI groups from the TRI database, thus affording a means of optimally evaluating the outcomes in individual patients.

Conclusion

We anticipate such a tool to become a starting point for more sophisticated measures in clinical outcomes, applicable not only in the context of tinnitus but also in other complex diseases where the integration of multiple variables is needed for a comprehensive evaluation of treatment response.

Outpatient Tinnitus Clinic, Self-Help Web Platform, or Mobile Application to Recruit Tinnitus Study Samples?

For understanding the heterogeneity of tinnitus, large samples are required. However, investigations on how samples recruited by different methods differ from each other are lacking. In the present study, three large samples each recruited by different means were compared: N = 5017 individuals registered at a self-help web platform for tinnitus (crowdsourcing platform Tinnitus Talk), N = 867 users of a smart mobile application for tinnitus (crowdsensing platform TrackYourTinnitus), and N = 3786 patients contacting an outpatient tinnitus clinic (Tinnitus Center of the University Hospital Regensburg). The three samples were compared regarding age, gender, and duration of tinnitus (month or years perceiving tinnitus; subjective report) using chi-squared tests. The three samples significantly differed from each other in age, gender and tinnitus duration (p < 0.05). Users of the TrackYourTinnitus crowdsensing platform were younger, users of the Tinnitus Talk crowdsourcing platform had more often female gender, and users of both newer technologies (crowdsourcing and crowdsensing) had more frequently acute/subacute tinnitus (<3 months and 4–6 months) as well as a very long tinnitus duration (>20 years). The implications of these findings for clinical research are that newer technologies such as crowdsourcing and crowdsensing platforms offer the possibility to reach individuals hard to get in contact with at an outpatient tinnitus clinic. Depending on the aims and the inclusion/exclusion criteria of a given study, different recruiting strategies (clinic and/or newer technologies) offer different advantages and disadvantages. In general, the representativeness of study results might be increased when tinnitus study samples are recruited in the clinic as well as via crowdsourcing and crowdsensing.

Measuring the Moment-to-Moment Variability of Tinnitus: The TrackYourTinnitus Smart Phone App

Tinnitus, the phantom perception of sound without a corresponding external sound, is a frequent disorder which causes significant morbidity. So far there is no treatment available that reliably reduces the tinnitus perception. The research is hampered by the large heterogeneity of tinnitus and the fact that the tinnitus perception fluctuates over time. It is therefore necessary to develop tools for measuring fluctuations of tinnitus perception over time and for analyzing data on single subject basis. However, this type of longitudinal measurement is difficult to perform using the traditional research methods such as paper-and-pencil questionnaires or clinical interviews. Ecological momentary assessment (EMA) represents a research concept that allows the assessment of subjective measurements under real-life conditions using portable electronic devices and thereby enables the researcher to collect longitudinal data under real-life conditions and high cost efficiency. Here we present a new method for recording the longitudinal development of tinnitus perception using a modern smartphone application available for iOS and Android devices with no costs for the users. The TrackYourTinnitus (TYT) app is available and maintained since April 2014. A number of 857 volunteers with an average age of 44.1 years participated in the data collection between April 2014 and February 2016. The mean tinnitus distress at the initial measurement was rated on average 13.9 points on the Mini-Tinnitus Questionnaire (Mini-TQ; max. 24 points). Importantly, we could demonstrate that the regular use of the TYT app has no significant negative influence on the perception of the tinnitus loudness nor on the tinnitus distress. The TYT app can therefore be proposed as a safe instrument for the longitudinal assessment of tinnitus perception in the everyday life of the patient.