Distinguishing levels of tinnitus distress

The Analogy between Tinnitus and Chronic Pain: A Phenomenological Approach

Tinnitus is an auditory sensation without external acoustic stimulation or significance, which may be lived as an unpleasant experience and impact the subject's quality of life. Tinnitus loudness, which is generally low, bears no relation to distress. Factors other than psychoacoustic (such as psychological factors) are therefore implicated in the way tinnitus is experienced. The aim of this article is to attempt to understand how tinnitus can, like chronic pain, generate a 'crisis' in the process of existence, which may go as far as the collapse of the subject. The main idea put forward in the present article is that tinnitus may be compared to the phenomenon of pain from the point of view of the way it is experienced. Although the analogy between tinnitus and pain has often been made in the literature, it has been limited to a parallel concerning putative physiopathological mechanisms and has never really been explored in depth from the phenomenological point of view. Tinnitus is comparable to pain inasmuch as it is felt, not perceived: it springs up (without intention or exploration), abolishes the distance between the subject and the sensation (there is only a subject and no object), and has nothing to say about the world. Like pain, tinnitus is formless and abnormal and can alter the normal order of the world with maximum intensity. Finally, tinnitus and pain enclose the subject within the limits of the body, which then becomes in excess. Tinnitus may be a source of suffering, which affects not only the body but a person's very existence and, in particular, its deployment in time. Plans are thus abolished, so time is no longer 'secreted', it is enclosed in an eternal present. If the crisis triggered by tinnitus is not resolved, the subject may buckle and collapse (depression) when their resources for resisting are depleted. The path may be long and winding from the moment when tinnitus emerges to when it assaults existence and its eventual integration into a new existential norm where tinnitus is no longer a source of disturbance.

Prediction Models for Tinnitus Presence and the Impact of Tinnitus on Daily Life: A Systematic Review

The presence of tinnitus does not necessarily imply associated suffering. Prediction models on the impact of tinnitus on daily life could aid medical professionals to direct specific medical resources to those (groups of) tinnitus patients with specific levels of impact. Models of tinnitus presence could possibly identify risk factors for tinnitus. We systematically searched the PubMed and EMBASE databases for articles published up to January 2021. We included all studies that reported on multivariable prediction models for tinnitus presence or the impact of tinnitus on daily life. Twenty-one development studies were included, with a total of 31 prediction models. Seventeen studies made a prediction model for the impact of tinnitus on daily life, three studies made a prediction model for tinnitus presence and one study made models for both. The risk of bias was high and reporting was poor in all studies. The most used predictors in the final impact on daily life models were depression- or anxiety-associated questionnaire scores. Demographic predictors were most common in final presence models. No models were internally or externally validated. All published prediction models were poorly reported and had a high risk of bias. This hinders the usability of the current prediction models. Methodological guidance is available for the development and validation of prediction models. Researchers should consider the importance and clinical relevance of the models they develop and should consider validation of existing models before developing new ones.

Deep learning-based electroencephalic diagnosis of tinnitus symptom

Tinnitus is a neuropathological phenomenon caused by the recognition of external sound that does not actually exist. Existing diagnostic methods for tinnitus are rather subjective and complicated medical examination procedures. The present study aimed to diagnose tinnitus using deep learning analysis of electroencephalographic (EEG) signals while patients performed auditory cognitive tasks. We found that, during an active oddball task, patients with tinnitus could be identified with an area under the curve of 0.886 through a deep learning model (EEGNet) using EEG signals. Furthermore, using broadband (0.5 to 50 Hz) EEG signals, an analysis of the EEGNet convolutional kernel feature maps revealed that alpha activity might play a crucial role in identifying patients with tinnitus. A subsequent time-frequency analysis of the EEG signals indicated that the tinnitus group had significantly reduced pre-stimulus alpha activity compared with the healthy group. These differences were observed in both the active and passive oddball tasks. Only the target stimuli during the active oddball task yielded significantly higher evoked theta activity in the healthy group compared with the tinnitus group. Our findings suggest that task-relevant EEG features can be considered as a neural signature of tinnitus symptoms and support the feasibility of EEG-based deep-learning approach for the diagnosis of tinnitus.

Characteristics of tinnitus and factors influencing its severity

Background and Objectives

There is a wealth of information regarding the treatment methods for tinnitus; however, the treatment available is unsatisfactory because of the following reasons: first, tinnitus has various etiologies and second, it has distinct heterogeneity among different individuals. Numerous studies have focused on understanding the causes of tinnitus severity, but the conclusions have been inconsistent. The purpose of the present study was to define factors that differentially influence subjectively perceived tinnitus severity.

Methods

Clinical data of patients with chronic tinnitus who visited our outpatient clinic from April 2020 to April 2021 were collected. Tinnitus Handicap Inventory (THI) and Tinnitus Evaluation Questionnaire (TEQ) were used to evaluate tinnitus severity among patients, and the independent factors influencing the severity of tinnitus were investigated by performing univariate and multivariate stepwise regression analyses.

Results

Eleven variables were associated with THI and TEQ scores, of which nine were identical. Multiple regression analyses results revealed that five variables had a significantly unique predictive effect on tinnitus severity based on THI and the TEQ scores. Three factors including Self-Rating Scale of Sleep (SRSS), change in loudness, and Self-Rating Anxiety Scale (SAS) were identical.

Conclusion

Sleep status, anxiety level, and change in loudness in patients with chronic tinnitus were significantly correlated with severity of tinnitus. Follow-up studies should investigate the causal relationship between these factors and tinnitus severity.

Recovering Hidden Responder Groups in Individuals Receiving Neurofeedback for Tinnitus

The widespread understanding that chronic tinnitus is a heterogeneous phenomenon with various neural oscillatory profiles has spurred investigations into individualized approaches in its treatment. Neurofeedback, as a non-invasive tool for altering neural activity, has become increasingly popular in the personalized treatment of a wide range of neuropsychological disorders. Despite the success of neurofeedback on the group level, the variability in the treatment efficacy on the individual level is high, and evidence from recent studies shows that only a small number of people can effectively modulate the desired aspects of neural activity. To reveal who may be more suitable, and hence benefit most from neurofeedback treatment, we classified individuals into unobserved subgroups with similar oscillatory trajectories during the treatment and investigated how subgroup membership was predicted by a series of characteristics. Growth mixture modeling was used to identify distinct latent subgroups with similar oscillatory trajectories among 50 individuals suffering from chronic subjective tinnitus (38 male, 12 female, mean age = 47.1 ± 12.84) across 15 neurofeedback training sessions. Further, the impact of characteristics and how they predicted the affiliation in the identified subgroups was evaluated by including measures of demographics, tinnitus-specific (Tinnitus Handicap Inventory) and depression variables, as well as subjective quality of life subscales (World Health Organization—Quality of Life Questionnaire), and health-related quality of life subscales (Short Form-36) in a logistic regression analysis. A latent class model could be fitted to the longitudinal data with a high probability of correctly classifying distinct oscillatory patterns into 3 different groups: non-responder (80%), responder (16%), and decliner (4%). Further, our results show that the health-related wellbeing subscale of the Short Form-36 questionnaire was differentially associated with the groups. However, due to the small sample size in the Responder group, we are not able to provide sufficient evidence for a distinct responder profile. Nevertheless, the identification of oscillatory change-rate differences across distinct groups of individuals provides the groundwork from which to tease apart the complex and heterogeneous oscillatory processes underlying tinnitus and the attempts to modify these through neurofeedback. While more research is needed, our results and the analytical approach presented may bring clarity to contradictory past findings in the field of tinnitus research, and eventually influence clinical practice.

Vascular-Metabolic Risk Factors and Psychological Stress in Patients with Chronic Tinnitus

Little is known about molecular correlates of chronic tinnitus. We examined interrelationships between vascular−metabolic risk factors, perceived stress, and other routine blood values in patients with chronic tinnitus. Two-hundred patients (51% female) were screened for 49 blood parameters pertaining to vascular−metabolic risk, immune function, and redox processes. They further completed perceived stress- and tinnitus-related distress questionnaires. Following descriptive analyses, gender-specific sets of age- and tinnitus-severity-adjusted regression models investigated associations between perceived stress and blood parameters. Patients reported mildly elevated levels of perceived stress. Elevated levels of total cholesterol (65% and 61% of female and male patients, respectively), non-HDL-c (43/50%), LDL-c (56/59%), and lipoprotein_a (28/14%) were accompanied by high rates of overweight (99/100%) and smoking (28/31%). A low-level inflammatory state was accompanied by reduced reactive oxygen species (ROS)-neutralizing capacity (reduced co-enzyme Q10 and SOD1 levels). Most vascular risk factors were not correlated with perceived stress, except for fibrinogen (ß = −0.34) as well as C-reactive protein (ß = −0.31, p < 0.05) in men, and MCV (ß = −0.26, p < 0.05) in women. Interrelations between blood parameters and stress levels need to be investigated within psychobehavioural frameworks across varying distress levels. Alongside psychological interventions, a low-level inflammatory state may be a route for pharmacological therapeutics.

An Albanian translation of a questionnaire for self-reported tinnitus assessment

OBJECTIVE

To our knowledge, there is no published study investigating the characteristics of people experiencing tinnitus in Albania. Such a study would be important, providing the basis for further research in this region and contributing to a wider understanding of tinnitus heterogeneity across different geographic locations. The main objective of this study was to develop an Albanian translation of a standardised questionnaire for tinnitus research, namely the European School for Interdisciplinary Tinnitus Research-Screening Questionnaire (ESIT-SQ). A secondary objective was to assess its applicability and usefulness by conducting an exploratory survey on a small sample of the Albanian tinnitus population.

DESIGN AND STUDY SAMPLE

Three translators were recruited to create the Albanian ESIT-SQ translation following good practice guidelines. Using this questionnaire, data from 107 patients attending otolaryngology clinics in Albania were collected.

RESULTS

Participants reporting various degrees of tinnitus symptom severity had distinct phenotypic characteristics. Application of a random forest approach on this preliminary dataset showed that self-reported hearing difficulty, and tinnitus duration, pitch and temporal manifestation were important variables for predicting tinnitus symptom severity.

CONCLUSIONS

Our study provided an Albanian translation of the ESIT-SQ and demonstrated that it is a useful tool for tinnitus profiling and subgrouping.

Functional impact of bothersome tinnitus on cognitive test performance

OBJECTIVE

Individuals with bothersome tinnitus frequently report their concentration is affected. Given that tinnitus is the leading service-connected disability compensated by the United States Department of Veterans Affairs, it is essential to determine whether tinnitus has a functional impact on the operational performance of Service members. Previous studies demonstrated that people with tinnitus perform more poorly on cognitive tests of selective attention and memory than those without tinnitus. This study aimed to compare performance between participants with and without tinnitus on visually based tests of selective attention (flanker task) and short-term memory (spatial letter location) that were self-administered under three auditory conditions (quiet, broadband noise and speech) using a tablet-based test protocol.

DESIGN

Experimental.

STUDY SAMPLE

Thirty participants with bothersome tinnitus and 30 control participants, matched for age and hearing loss.

RESULTS

The results revealed a significantly larger flanker effect and shorter memory span in the tinnitus group compared to the control group, consistent with previous studies. Performance accuracy was comparable between the groups.

CONCLUSIONS

The results suggest bothersome tinnitus may affect cognitive efficiency more than cognitive performance. The tablet-based protocol has the potential to be implemented clinically as a functional measure of the impact of bothersome tinnitus on concentration.

Tinnitus and tinnitus disorder: Theoretical and operational definitions (an international multidisciplinary proposal)

As for hypertension, chronic pain, epilepsy and other disorders with particular symptoms, a commonly accepted and unambiguous definition provides a common ground for researchers and clinicians to study and treat the problem. The WHO's ICD11 definition only mentions tinnitus as a nonspecific symptom of a hearing disorder, but not as a clinical entity in its own right, and the American Psychiatric Association's DSM-V doesn't mention tinnitus at all. Here we propose that the tinnitus without and with associated suffering should be differentiated by distinct terms: "Tinnitus" for the former and "Tinnitus Disorder" for the latter. The proposed definition then becomes "Tinnitus is the conscious awareness of a tonal or composite noise for which there is no identifiable corresponding external acoustic source, which becomes Tinnitus Disorder "when associated with emotional distress, cognitive dysfunction, and/or autonomic arousal, leading to behavioural changes and functional disability.". In other words "Tinnitus" describes the auditory or sensory component, whereas "Tinnitus Disorder" reflects the auditory component and the associated suffering. Whereas acute tinnitus may be a symptom secondary to a trauma or disease, chronic tinnitus may be considered a primary disorder in its own right. If adopted, this will advance the recognition of tinnitus disorder as a primary health condition in its own right. The capacity to measure the incidence, prevalence, and impact will help in identification of human, financial, and educational needs required to address acute tinnitus as a symptom but chronic tinnitus as a disorder.

The Association Between Effectiveness of Tinnitus Intervention and Cognitive Function-A Systematic Review

Tinnitus refers to the perception of sound in the absence of an external stimulus. This can be problematic and can lead to health problems in some sufferers, including effects on cognitive functions such as attention and memory. Although several studies have examined the effectiveness of tinnitus interventions, e.g., cognitive behavioral therapy and sound therapy, it is still unclear as to the overall quality and limitations of these studies and whether their results could be generalized. Clarification is also needed as to whether poor cognitive function will lead to a less favorable intervention outcome in tinnitus patients. The present systematic review was therefore designed to critically appraise and synthesize findings from randomized controlled trials (RCTs) of tinnitus intervention and its effects on cognition. The methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Medline (PubMed), Embase, and PsycINFO were searched. Only RCTs that compared the effectiveness of a tinnitus intervention and a measure of cognitive function in adult participants with tinnitus were included. A total of 8 studies involving 610 participants tested using 11 cognitive function assessment tools (e.g., Stroop Color and Word Test and Visual Continuous Performance Task) and 5 tinnitus intervention outcome measurements (e.g., Tinnitus Handicap Inventory and Tinnitus Questionnaire) were included and analyzed. The outcomes of the review suggest that tinnitus intervention not only facilitates tinnitus management but also improves cognitive functions. It is likely that cognition and emotion play an important role in a patient's adjustment to tinnitus. Whether cognition can predict treatment outcomes is unclear due to insufficient evidence. Future research is needed using a standardized assessment protocol focusing on the effect of sound-based interventions on tinnitus severity and cognitive functions. Studies on whether cognitive function measurement can be used as a predictor for the effectiveness of tinnitus therapy are also needed.

A Review and a Framework of Variables for Defining and Characterizing Tinnitus Subphenotypes

Tinnitus patients can present with various characteristics, such as those related to the tinnitus perception, symptom severity, and pattern of comorbidities. It is speculated that this phenotypic heterogeneity is associated with differences in the underlying pathophysiology and personal reaction to the condition. However, there is as yet no established protocol for tinnitus profiling or subtyping, hindering progress in treatment development. This review summarizes data on variables that have been used in studies investigating phenotypic differences in subgroups of tinnitus, including variables used to both define and compare subgroups. A PubMed search led to the identification of 64 eligible articles. In most studies, variables for subgrouping were chosen by the researchers (hypothesis-driven approach). Other approaches included application of unsupervised machine-learning techniques for the definition of subgroups (data-driven), and subgroup definition based on the response to a tinnitus treatment (treatment response). A framework of 94 variable concepts was created to summarize variables used across all studies. Frequency statistics for the use of each variable concept are presented, demonstrating those most and least commonly assessed. This review highlights the high dimensionality of tinnitus heterogeneity. The framework of variables can contribute to the design of future studies, helping to decide on tinnitus assessment and subgrouping.

Stress and Tinnitus; Transcutaneous Auricular Vagal Nerve Stimulation Attenuates Tinnitus-Triggered Stress Reaction

Introduction

Tinnitus can become a strong stressor for some individuals, leading to imbalance of the autonomous nervous system with reduction of parasympathetic activity. It can manifest itself as sleep disturbances, anxiety and even depression. This condition can be reversed by bioelectrical vagal nerve stimulation (VNS). Conventional invasive VNS is an approved treatment for epilepsy and depression. Transcutaneous VNS (taVNS) stimulating the auricular branch of the vagus nerve has been shown to activate the vagal pathways similarly as an implanted VNS. Therefore, taVNS might also be a therapeutic alternative in health conditions such as tinnitus-related mental stress (TRMS). This retrospective study in 171 TRMS patients reports the clinical features, psychophysiological characteristics, and results of the heart rate variability (HRV) tests before and after test-taVNS. This study also reports the therapy outcomes of 113 TRMS patients treated with taVNS, in combination with standard tinnitus therapy.

Methods

Diagnostic tinnitus and hearing profiles were defined. To detect possible cardiac adverse effects, test-taVNS with heart rate monitoring as well as pre- and post-stimulation HRV tests were performed. Daily taVNS home therapy was prescribed thereafter. To assess therapeutic usefulness of taVNS, 1-year follow-up outcome was studied. Results of HRV tests were retrospectively analyzed and correlated to diagnostic data.

Results

The large majority of patients with TRMS suffer from associated symptoms such as sleep disturbances and anxiety. Baseline HRV data showed that more than three quarters of the 171 patients had increased sympathetic activity before test-taVNS. Test-taVNS shifted mean values of different HRV parameters toward increased parasympathetic activity in about 80% of patients. Test-taVNS did not cause any cardiac or other side effects. No significant adverse effects were reported in follow-up questionnaires.

Conclusion

TRMS is an example of a stress condition in which patients may benefit from taVNS. As revealed by HRV, test-taVNS improved parasympathetic function, most efficiently in patients with a low starting HRV level. Our tinnitus treatment program, including taVNS, effectively alleviated tinnitus stress and handicap. For wider clinical use, there is a great need for more knowledge about the optimal methodology and parameters of taVNS.

A scoping review to catalogue tinnitus problems in children

BACKGROUND

The reported prevalence of tinnitus in children is similar to that in adults. However, unlike adults, there is relatively little understanding of the tinnitus-related problems children experience. Knowledge of the problems experienced by adults has led to the development of numerous clinical questionnaires used by health professionals in assessment and treatment practices; to date no child-specific questionnaire measure of tinnitus has been developed. To support development of a questionnaire measure of tinnitus in children, the aim of this scoping review was to catalogue the peer-reviewed and grey scientific literature according to 1) the methods used to identify problems experienced by children with tinnitus, 2) tinnitus-related problems observed in or reported by children, and 3) research recommendations suggested by investigators with regards to tinnitus in children.

METHODS

A scoping review was conducted following an established methodological framework. Records were included where a tinnitus-related problem was reported in a child 18 years or younger, and tinnitus was reported as the primary complaint. Tinnitus problems were extracted and categorised into problem themes.

RESULTS

Thirty-five records met the inclusion criteria for this review. Methods used to identify tinnitus-related problems in children, and the number and range of problems reported, varied across the records. Symptom impact was summarised according to six problem themes; Physical health, Cognitive health, Hearing and listening, Emotional health, Quality of life, and Feeling different/isolated. Identified research recommendations highlighted a demand for more standardised approaches.

CONCLUSIONS

The findings evidence the detrimental impact tinnitus can have on a child's quality of life and emotional wellbeing. The current British Society of Audiology Tinnitus in Children Practice Guidance recommends management practices to address the most broadly reported problems identified in this review; sleep difficulties, emotional difficulties, and concentration and hearing problems at school. Given the finding of this review, we suggest problems relating to the impact of tinnitus on quality of life and feelings of isolation are also important problem domains to consider when managing a child who has tinnitus. Current variability in the approach to identifying children's tinnitus problems underlines the importance of developing a standardised and dedicated measure of tinnitus in children.

Measuring the Impact of Tinnitus on Aided Listening Effort Using Pupillary Response

Tinnitus can have serious impact on a person's life and is a common auditory symptom that is especially comorbid with hearing loss. This study investigated processing effort required for speech recognition in a group of hearing-impaired people with tinnitus and a control group (CG) of hearing-impaired people without tinnitus by means of pupillary response. Furthermore, the relationship between the pupillary response, self-rating measures of tinnitus severity, and fatigue was examined. Participants performed a speech-in-noise task with a competing four-talker babble at two speech intelligibility levels (50% and 95%) with either an active or inactive noise-reduction scheme while the pupillary response was recorded. Tinnitus participants showed significantly smaller time-dependent pupil dilations and significantly higher fatigue ratings. No correlation was found for the tinnitus severity and pupillary response, but a significant correlation was found between the tinnitus severity and fatigue. As participants with tinnitus generally reported higher fatigue and showed smaller task-evoked pupil dilations, it was speculated that this may suggest an increased activity of the parasympathetic nervous system, which governs the bodily response during rest. The finding that tinnitus participants showed higher fatigue has clinical implications, highlighting the importance of taking steps to decrease the risk of developing long-term fatigue. Finally, the tinnitus participants showed reduced pupillary responses when noise reduction was activated, suggesting a reduced effort from hearing aid signal processing.

Association between subjective tinnitus and cognitive performance: protocol for systematic review and meta-analysis

INTRODUCTION

Subjective tinnitus is very common and has a number of comorbid associations including depression, sleep disturbance and concentration difficulties. Concentration difficulties may be observable in people with tinnitus through poorer behavioural performance in tasks thought to measure specific cognitive domains such as attention and memory (ie, cognitive performance). Several reviews have discussed the association between tinnitus and cognition; however, none to date have investigated the association between tinnitus and cognitive performance through meta-analysis with reference to an established theoretical taxonomy. Furthermore, there has been little overlap between sets of studies that have been included in previous reviews, potentially contributing to the typically mixed findings that are reported.

METHODS AND ANALYSIS

This systematic review aims to comprehensively review the literature using an established theoretical taxonomy and quantitatively synthesise relevant data to determine associations between subjective tinnitus and cognitive performance. Methods are reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. All study designs will be eligible for inclusion with no date restrictions on searches. Studies eligible for inclusion must contain adult participants (≥18 years) with subjective tinnitus and a behavioural measure of cognitive performance. Meta-analysis will be reported via correlation for the association between tinnitus and cognitive performance.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. Findings will be reported in a student thesis, at national and international , ear, nose and throat/audiology conferences and by peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42018085528.

Cholinergic Hypofunction in Presbycusis-Related Tinnitus With Cognitive Function Impairment: Emerging Hypotheses

Presbycusis (age-related hearing loss) is a potential risk factor for tinnitus and cognitive deterioration, which result in poor life quality. Presbycusis-related tinnitus with cognitive impairment is a common phenotype in the elderly population. In these individuals, the central auditory system shows similar pathophysiological alterations as those observed in Alzheimer's disease (AD), including cholinergic hypofunction, epileptiform-like network synchronization, chronic inflammation, and reduced GABAergic inhibition and neural plasticity. Observations from experimental rodent models indicate that recovery of cholinergic function can improve memory and other cognitive functions via acetylcholine-mediated GABAergic inhibition enhancement, nicotinic acetylcholine receptor (nAChR)-mediated anti-inflammation, glial activation inhibition and neurovascular protection. The loss of cholinergic innervation of various brain structures may provide a common link between tinnitus seen in presbycusis-related tinnitus and age-related cognitive impairment. We hypothesize a key component of the condition is the withdrawal of cholinergic input to a subtype of GABAergic inhibitory interneuron, neuropeptide Y (NPY) neurogliaform cells. Cholinergic denervation might not only cause the degeneration of NPY neurogliaform cells, but may also result in decreased AChR activation in GABAergic inhibitory interneurons. This, in turn, would lead to reduced GABA release and inhibitory regulation of neural networks. Reduced nAChR-mediated anti-inflammation due to the loss of nicotinic innervation might lead to the transformation of glial cells and release of inflammatory mediators, lowering the buffering of extracellular potassium and glutamate metabolism. Further research will provide evidence for the recovery of cholinergic function with the use of cholinergic input enhancement alone or in combination with other rehabilitative interventions to reestablish inhibitory regulation mechanisms of involved neural networks for presbycusis-related tinnitus with cognitive impairment.

The Effectiveness of the Progression of Widex Zen Tinnitus Therapy: A Pilot Study

PURPOSE

The aim of this study was to measure the progression of benefits to individuals with tinnitus from providing informational counseling, hearing aids, a brief tinnitus activities treatment and Zen therapy.

METHOD

Several magnitude estimation scales and tinnitus handicap scales were administered for the duration of the study to 20 participants.

RESULTS

Results indicated that all participants benefited from this sequential approach of providing different components of this tinnitus treatment. Large benefits were observed following the tinnitus activities treatment and the Zen treatments.

CONCLUSION

We conclude that the progressive approach of treatment demonstrated here should be of benefit to most individuals with tinnitus and that the Widex Zen sound therapy is a worthwhile treatment for many tinnitus sufferers.

Non-invasive vagus nerve stimulation reduces sympathetic preponderance in patients with tinnitus

CONCLUSION

Transcutaneous vagal nerve stimulation (tVNS) might offer a targeted, patient-friendly, and low-cost therapeutic tool for tinnitus patients with sympathovagal imbalance.

OBJECTIVES

Conventionally, VNS has been performed to treat severe epilepsy and depression with an electrode implanted to the cervical trunk of vagus nerve. This study investigated the acute effects of tVNS on autonomic nervous system (ANS) imbalance, which often occurs in patients with tinnitus-triggered stress.

METHODS

This study retrospectively analysed records of 97 patients who had undergone ANS function testing by heart rate variability (HRV) measurement immediately before and after a 15-60 min tVNS stimulation.

RESULTS

The pre-treatment HRV recording showed sympathetic preponderance/reduced parasympathetic activity in about three quarters (73%) of patients. Active tVNS significantly increased variability of R-R intervals in 75% of patients and HRV age was decreased in 70% of patients. Either the variability of R-R intervals was increased or the HRV age decreased in 90% of the patients. These results indicate that tVNS can induce a shift in ANS function from sympathetic preponderance towards parasympathetic predominance. tVNS caused no major morbidity, and heart rate monitoring during the tVNS treatment showed no cardiac or circulatory effects (e.g. bradycardia) in any of the patients.

Deep brain stimulation of the inferior colliculus in the rodent suppresses tinnitus

In animal models of tinnitus pathological neuronal activity has been demonstrated. Deep brain stimulation disrupts pathological neuronal activity and might therefore be a potential treatment for patients who suffer severely from tinnitus. In this study, the effect of DBS in the inferior colliculi is investigated in an animal model of tinnitus. The external cortex of the inferior colliculus was targeted because of the key position of the inferior colliculus within the auditory network and the relation of the external cortex with the limbic system. In this study we show the effect of DBS in the inferior colliculus on tinnitus using a within-subject experimental design. After noise trauma, rats showed a significant increase in gap:no gap ratio of the gap-induced prepulse inhibition at 16 and 20kHz (p<0.05), indicating the presence of tinnitus in these frequency bands. During DBS the gap:no gap ratio returned back to baseline (p<0.05). Hearing thresholds before and during DBS did not differ, indicating that hearing function is probably not impaired by electrical stimulation. In summary, this study shows that DBS of the inferior colliculi is effective in reducing behavioral signs of tinnitus in an animal model. Impaired hearing function could not be objectified as a side effect of stimulation.

Which tinnitus-related characteristics affect current health-related quality of life and depression? A cross-sectional cohort study

Tinnitus is sometimes associated with lower health-related quality of life (HRQoL) and depressive symptoms. However, only limited evidence exists identifying which tinnitus characteristics are responsible for these associations. The aim of this cross-sectional study was to assess associations between tinnitus, HRQoL, depressive symptoms, subjective tinnitus loudness and audiometrically assessed tinnitus characteristics (e.g., hearing threshold). Two hundred and eight outpatients reporting tinnitus completed questionnaires on tinnitus (Tinnitus Handicap Inventory, THI), HRQoL (World-Health-Organisation Quality of Life Short Form Survey, WHOQOL-BREF), and depressive symptoms (Beck Depression Inventory, BDI), and underwent audiometry. Patients with higher THI scores exhibited significantly lower HRQoL, and higher depression scores. THI total-score, THI subscales, and subjective tinnitus loudness explained significant variance of WHOQOL-BREF and BDI. Audiometrically measured features were not associated with WHOQOL-BREF or BDI. Overall, we confirmed findings that different features of tinnitus are associated with HRQoL and depressive symptoms but not with audiometrically assessed tinnitus characteristics. Consequently, physicians should evaluate THI total score, its sub-scores, and subjective tinnitus loudness to reliably and quickly identify patients who potentially suffer from depressive symptoms or significantly lower HRQoL. Supporting these patients early might help to prevent the development of reactive depressive symptoms and impairment of HRQoL.

Differences Among Patients That Make Their Tinnitus Worse or Better

PURPOSE

Our objective was to identify activities that influence tinnitus and to determine if conditional probabilities exist among such variables.

METHOD

Two hundred fifty-eight patients were asked the following two questions: "When you have your tinnitus, which of the following makes it worse?" and "Which of the following reduces your tinnitus?"

RESULTS

Things that made tinnitus better included noise (31%) and relaxation (15%). Things that made tinnitus worse included being in a quiet place (48%), stress (36%), being in a noisy place (32%), and lack of sleep (27%). Almost 6% of patients suggested coffee/tea and 4% said certain foods made their tinnitus worse. Conditional probabilities indicated that for those whose tinnitus is not worse in quiet, it is usually not reduced by noise. For those whose tinnitus is not worse in noise, it is usually not reduced in quiet.

CONCLUSION

There are dramatic differences among patients. Such differences need to be considered in planning treatments.

The impact of tinnitus characteristics and associated variables on tinnitus-related handicap

OBJECTIVE

This study aimed to determine the characteristics of tinnitus and tinnitus-related variables and explore their possible relationship with tinnitus-related handicap.

METHODS

Eighty-one patients with chronic tinnitus were included. The study protocol measured hearing status, tinnitus pitch, loudness, maskability and loudness discomfort levels. All patients filled in the Tinnitus Sample Case History Questionnaire, the Hyperacusis Questionnaire and the Tinnitus Handicap Inventory. The relationship of each variable with the Tinnitus Handicap Inventory score was evaluated by univariate and multivariate analyses.

RESULTS

Five univariables were associated with the Tinnitus Handicap Inventory score: loudness discomfort level, subjective tinnitus loudness, tinnitus awareness, noise intolerance and Hyperacusis Questionnaire score. Multiple regression analysis showed that the Hyperacusis Questionnaire score and tinnitus awareness were independently associated with the Tinnitus Handicap Inventory score.

CONCLUSION

Hyperacusis and tinnitus awareness were independently associated with the Tinnitus Handicap Inventory score. Questionnaires on tinnitus and hyperacusis are especially suited to providing additional insight into tinnitus-related handicap and are therefore useful for evaluating tinnitus patients.

Abnormal Auditory Gain in Hyperacusis: Investigation with a Computational Model

Hyperacusis is a frequent auditory disorder that is characterized by abnormal loudness perception where sounds of relatively normal volume are perceived as too loud or even painfully loud. As hyperacusis patients show decreased loudness discomfort levels (LDLs) and steeper loudness growth functions, it has been hypothesized that hyperacusis might be caused by an increase in neuronal response gain in the auditory system. Moreover, since about 85% of hyperacusis patients also experience tinnitus, the conditions might be caused by a common mechanism. However, the mechanisms that give rise to hyperacusis have remained unclear. Here, we have used a computational model of the auditory system to investigate candidate mechanisms for hyperacusis. Assuming that perceived loudness is proportional to the summed activity of all auditory nerve (AN) fibers, the model was tuned to reproduce normal loudness perception. We then evaluated a variety of potential hyperacusis gain mechanisms by determining their effects on model equal-loudness contours and comparing the results to the LDLs of hyperacusis patients with normal hearing thresholds. Hyperacusis was best accounted for by an increase in non-linear gain in the central auditory system. Good fits to the average patient LDLs were obtained for a general increase in gain that affected all frequency channels to the same degree, and also for a frequency-specific gain increase in the high-frequency range. Moreover, the gain needed to be applied after subtraction of spontaneous activity of the AN, which is in contrast to current theories of tinnitus generation based on amplification of spontaneous activity. Hyperacusis and tinnitus might therefore be caused by different changes in neuronal processing in the central auditory system.

A novel treatment for tinnitus and tinnitus-related cognitive difficulties using computer-based cognitive training and D-cycloserine

IMPORTANCE

Tinnitus affects more than 40 million people in the Unites States, and cognitive difficulties are among the most commonly associated symptoms.

OBJECTIVE

To test the feasibility and preliminarily the effectiveness of using a putative neuroplasticity-enhancing drug, D-cycloserine, to facilitate a computer-assisted CT program for improving tinnitus bother and related cognitive difficulties.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, randomized clinical trial at an outpatient academic medical center of 34 participants aged 35 to 65 years with subjective, unilateral or bilateral, nonpulsatile tinnitus of at least 6 months' duration.

INTERVENTIONS

Five weeks of twice-weekly computer-based CT with either 250 mg D-cycloserine or placebo orally prior to computer CT sessions.

MAIN OUTCOMES AND MEASURES

Difference in the change in Tinnitus Functional Index (TFI) score between the 2 groups.

RESULTS

After excluding 1 participant lost to follow-up, 1 who withdrew, 1 who did not complete 90% of sessions, and 1 outlier, 30 participants were included in the analysis. The D-cycloserine plus CT group showed a significant improvement in median TFI score (-5.8 [95% CI, -9.4 to -1.1]) and self-reported cognitive deficits (-4.5 [95% CI, -11.5 to -1.0]), but the placebo group did not (-1.0 [95% CI, -11.7 to 4.9] and -2.0 [95% CI, -5.1 to 2.0], respectively). After controlling for age and duration of tinnitus, there was no significant difference in TFI score change between the 2 groups (P = .41). After confounders were controlled for, the D-cycloserine group demonstrated a significantly greater improvement in self-reported cognitive deficits as compared with the placebo group (P = .03). No serious adverse events were reported.

CONCLUSIONS AND RELEVANCE

Use of a computer-based CT program with a putative neuroplasticity-sensitizing drug, D-cycloserine, was feasible and well tolerated. With the limited sample size, the adjuvant use of D-cycloserine was no more effective than placebo at improving tinnitus bother. The finding that D-cycloserine use was more effective than placebo at improving self-reported cognitive difficulties could be important given the high rate of concern for cognitive deficits in patients with tinnitus. D-cycloserine and other putative neuroplasticity-facilitating agents could be investigated in the future as a strategy to enhance neuroplasticity-based tinnitus treatments.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01550796.

A scientific cognitive-behavioral model of tinnitus: novel conceptualizations of tinnitus distress

The importance of psychological factors in tinnitus distress has been formally recognized for almost three decades. The psychological understanding of why tinnitus can be a distressing condition posits that it becomes problematic when it acquires an emotive significance through cognitive processes. Principle therapeutic efforts are directed at reducing or removing the cognitive (and behavioral) obstacles to habituation. Here, the evidence relevant to a new psychological model of tinnitus is critically reviewed. The model posits that patients' interpretations of tinnitus and the changes in behavior that result are given a central role in creating and maintaining distress. The importance of selective attention and the possibility that this leads to distorted perception of tinnitus is highlighted. From this body of evidence, we propose a coherent cognitive-behavioral model of tinnitus distress that is more in keeping with contemporary psychological theories of clinical problems (particularly that of insomnia) and which postulates a number of behavioral processes that are seen as cognitively mediated. This new model provides testable hypotheses to guide future research to unravel the complex mechanisms underpinning tinnitus distress. It is also well suited to define individual symptomatology and to provide a framework for the delivery of cognitive-behavioral therapy.

Autobiographical memory specificity in patients with tinnitus versus patients with depression and normal controls

Several studies show that patients with depression and post-traumatic stress disorder respond with fewer specific autobiographical memories in a cued memory task (i.e. the autobiographical memory test; AMT) compared to healthy controls. One previous study found this phenomenon among tinnitus patients as well (Andersson, Ingerholt, & Jansson, 2003). The aim of this study was to replicate the previous study with an additional control group of depressed patients and memory errors as measured with the AMT as an additional outcome. We included 20 normal hearing tinnitus patients, 20 healthy controls and 20 persons diagnosed with clinical depression. The AMT was administered together with self-report measures of depression, anxiety and tinnitus distress. Both the tinnitus and depression groups differed from the healthy control group in that they reported fewer specific autobiographical memories. There were, however, differences between the tinnitus and depression groups in terms of the errors made on the AMT. The depression group had more overgeneral memories than the normal control group, whereas the tinnitus group did not differ from the control group on this memory error. The tinnitus group had more semantic associations and non-memories than the other two groups, suggesting that executive functioning may play a role for the tinnitus group when completing the AMT. Clinical and theoretical implications of the findings are discussed.

Internet-based cognitive behaviour therapy for tinnitus patients delivered in a regular clinical setting: outcome and analysis of treatment dropout

Cognitive behaviour therapy (CBT) can reduce tinnitus distress but is not available for most patients. Therapist guided, internet-based CBT (ICBT) increase availability and has been shown to be effective. However, the initial positive results need to be replicated in larger samples, and treatment dropout has not been thoroughly studied. Moreover, it has not been evaluated if a low-intensity version of ICBT without therapist contact could be an alternative for patients who do not need or are able to manage the full ICBT-program. This study evaluated two parallel interventions delivered in regular care: ICBT for tinnitus distress (n = 293) and a low-intensity version of ICBT (n = 81) for patients with lower levels of tinnitus distress. We also explored predictors of dropout from ICBT and if dropout influences outcome. Tinnitus Reaction Questionnaire (Wilson, Henry, Bowen, & Haralambous, 1991) was used as the primary outcome. Secondary outcomes were measures of depression, anxiety, sleep, and sound sensitivity. Significant reductions following ICBT were found on all measures after treatment and also at a three-month follow-up. Patients receiving low-intensity ICBT showed a significant reduction in distress, even when they had low levels of distress initially. Treatment dropout was preceded by an increase in days spent at each treatment step but not by an increased distress. Early dropout was related to worse outcome. ICBT can be used in a regular clinical setting to reduce tinnitus distress. Early dropouts may need additional management. For help-seeking patients with lower distress, a low-intensity version of ICBT can be used.

Psychoacoustic tinnitus loudness and tinnitus-related distress show different associations with oscillatory brain activity

Background

The phantom auditory perception of subjective tinnitus is associated with aberrant brain activity as evidenced by magneto- and electroencephalographic studies. We tested the hypotheses (1) that psychoacoustically measured tinnitus loudness is related to gamma oscillatory band power, and (2) that tinnitus loudness and tinnitus-related distress are related to distinct brain activity patterns as suggested by the distinction between loudness and distress experienced by tinnitus patients. Furthermore, we explored (3) how hearing impairment, minimum masking level, and (4) psychological comorbidities are related to spontaneous oscillatory brain activity in tinnitus patients.

Methods and Findings

Resting state oscillatory brain activity recorded electroencephalographically from 46 male tinnitus patients showed a positive correlation between gamma band oscillations and psychoacoustic tinnitus loudness determined with the reconstructed tinnitus sound, but not with the other psychoacoustic loudness measures that were used. Tinnitus-related distress did also correlate with delta band activity, but at electrode positions different from those associated with tinnitus loudness. Furthermore, highly distressed tinnitus patients exhibited a higher level of theta band activity. Moreover, mean hearing loss between 0.125 kHz and 16 kHz was associated with a decrease in gamma activity, whereas minimum masking levels correlated positively with delta band power. In contrast, psychological comorbidities did not express significant correlations with oscillatory brain activity.

Conclusion

Different clinically relevant tinnitus characteristics show distinctive associations with spontaneous brain oscillatory power. Results support hypothesis (1), but exclusively for the tinnitus loudness derived from matching to the reconstructed tinnitus sound. This suggests to preferably use the reconstructed tinnitus spectrum to determine psychoacoustic tinnitus loudness. Results also support hypothesis (2). Moreover, hearing loss and minimum masking level correlate with oscillatory power in distinctive frequency bands. The lack of an association between psychological comorbidities and oscillatory power may be attributed to the overall low level of mental health problems in the present sample.

Altered networks in bothersome tinnitus: a functional connectivity study

Background

The objective was to examine functional connectivity linked to the auditory system in patients with bothersome tinnitus. Activity was low frequency (< 0.1 Hz), spontaneous blood oxygenation level-dependent (BOLD) responses at rest. The question was whether the experience of chronic bothersome tinnitus induced changes in synaptic efficacy between co-activated components. Functional connectivity for seed regions in auditory, visual, attention, and control networks was computed across all 2 mm³ brain volumes in 17 patients with moderate-severe bothersome tinnitus (Tinnitus Handicap Index: average 53.5 ± 3.6 (range 38-76)) and 17 age-matched controls.

Results

In bothersome tinnitus, negative correlations reciprocally characterized functional connectivity between auditory and occipital/visual cortex. Negative correlations indicate that when BOLD response magnitudes increased in auditory or visual cortex they decreased in the linked visual or auditory cortex, suggesting reciprocally phase reversed activity between functionally connected locations in tinnitus. Both groups showed similar connectivity with positive correlations within the auditory network. Connectivity for primary visual cortex in tinnitus included extensive negative correlations in the ventral attention temporoparietal junction and in the inferior frontal gyrus and rostral insula - executive control network components. Rostral insula and inferior frontal gyrus connectivity in tinnitus also showed greater negative correlations in occipital cortex.

Conclusions

These results imply that in bothersome tinnitus there is dissociation between activity in auditory cortex and visual, attention and control networks. The reciprocal negative correlations in connectivity between these networks might be maladaptive or reflect adaptations to reduce phantom noise salience and conflict with attention to non-auditory tasks.

Treatment of tinnitus in the elderly: a controlled trial of cognitive behavior therapy

The aim of the study was to investigate the effects of cognitive behavioral therapy (CBT) in elderly people with tinnitus (<65 years). Thirty-seven patients were called in for a structured interview. Following exclusion, twenty-three participated in the trial. All participants underwent medical ear, nose, and throat (ENT) examination, audiometry, and tinnitus matchings. A randomized controlled design with a waiting list control group was used. A CBT treatment package was delivered in six weekly two hour group sessions. Outcome was measured using validated self-report inventories and daily diary ratings of annoyance, loudness and sleep quality for one week pretreatment, post-treatment. A three month follow-up was included at which time all participants had received treatment, but in a shorter format for the control group. Results showed statistically significant reductions of tinnitus-related distress. Thus, CBT was better than no treatment, but the particular aspects of CBT that contributed to the effects can not be established. In conclusion, the findings give some support for the use of group CBT for elderly people with tinnitus.

Tinnitus impairs cognitive efficiency

Many people who complain of tinnitus say that the noises impair their mental concentration. This complaint was investigated by self-report (primarily the Cognitive Failures Questionnaire) and by means of five cognitive tasks, four presented via laptop computer and one given manually. The tasks measured performance under single- and dual-task conditions and included tests of sustained attention, reaction time, verbal fluency and immediate and delayed memory. Two groups of outpatients attending audiological clinics (tinnitus, n = 43; hearing impairment, n = 17) were compared with non-clinical volunteers (n = 32). The results replicated earlier findings that tinnitus outpatients report significantly more everyday cognitive failures than do controls. The tinnitus group responded significantly more slowly than the two control groups on the variable fore-period reaction time task under dual-task conditions. In general, comparisons between the groups on other tasks showed equivalent performance, but both clinical groups performed more poorly than non-clinical controls on verbal fluency. We conclude that cognitive inefficiency in tinnitus participants is related to the control of attentional processes, consistent with our earlier theoretical speculation about the nature of tinnitus complaint and with published findings on the effects of chronic pain on cognitive processes.

Physiological and psychological stress reactivity in chronic tinnitus

Several models of tinnitus maintenance emphasize the importance of cognitive, emotional and psychophysiological processes. These factors contribute to distress in patients with decompensated tinnitus symptoms. We investigated whether tinnitus patients show increased physiological levels of arousal, more intense stress reactivity patterns and exaggerated psychological strain compared to healthy controls. Seventy tinnitus patients and 55 healthy controls underwent various stress tests. Muscular reactivity and peripheral arousal as well as strain ratings were assessed. Tinnitus patients reported significantly more strain during stress tests compared to healthy controls. Few physiological reactivity patterns differed significantly between the two groups. The physiological data thus only partly supported a hyperreactivity hypothesis. Strain reports and physiological data were only marginally correlated. Tinnitus patients show maladaptive appraisal processes during stress exposure, yet physiological reactivity is only slightly affected. Treatment programs for patients with decompensated tinnitus symptoms should account for appraisal processes and coping mechanisms in stressful situations.

When Tinnitus Loudness and Annoyance Are Discrepant: Audiological Characteristics and Psychological Profile

This study evaluates sociodemographic and clinical characteristics of patients reporting discrepant levels of tinnitus loudness and annoyance. 4958 subjects recruited from a national tinnitus association completed a comprehensive screening questionnaire including Klockhoff and Lindblom's loudness grading system and the psychometric Mini-TQ (Tinnitus Questionnaire). There was a moderate correlation of 0.45 between loudness and annoyance. Of the subjects reporting very loud tinnitus, about one third had only mild or moderate annoyance scores. They were not different from those with high annoyance regarding age, gender and tinnitus duration, but annoyance was increased when subjects had additional hearing loss (OR = 1.71), vertigo/dizziness (OR = 1.94) or hyperacusis (OR = 4.96). Another significant predictor was history of neurological disease (OR = 3.16). Subjects reported low annoyance despite high loudness more often if not feeling low/depressed and not considering themselves as victims of their noises. A specific psychological profile was found to characterize annoyed tinnitus sufferers. Permanent awareness of the noises, decreased ability to ignore them and concentration difficulties were reported frequently even when overall annoyance scores were comparatively low. It is concluded that the coexistence of tinnitus with hearing loss, vertigo/dizziness and hyperacusis as complicating otological conditions seems to be of clinical relevance for the prediction of high annoyance levels. Tinnitus loudness and annoyance are not necessarily congruent and should be assessed separately.

Psychological, neural, endocrine, and immune study of stress in tinnitus patients: any correlation between psychometric and biochemical measures?

OBJECTIVES

The present study was carried out in tinnitus patients in order to study the psychological distress and the biochemical measures of this stressful condition. Psychological features were compared to immune and neuroendocrine parameters in order to verify in these subjects the possible presence of psychological and somatic responses to stress.

METHODS

We studied 85 tinnitus patients who underwent hematochemical immune tests: lymphocyte subpopulations (CD3; CD4; CD3+CD4; CD8; CD19; CD16NK; CD3+CD16+CD56; and CD4/CD8), cortisol, adrenocorticotropic hormone, beta-endorphin, prolactin, and urinary catecholamine.

RESULTS

Clinically, significant scores were obtained for hysteria, depression, paranoia, hypochondrias, and social introversion; and high scores were obtained for anxiety, depression, care for health, difficulty of treatment, low self-esteem, family and work difficulties, and social discomfort. There was a low to medium level of self-perception of stress. The less a subject felt stressed, the higher was his or her satisfaction level in the areas of psychological and physical functioning. The scores on the tests and the biochemical measures did not show a significant correlation, but there was a tendency to correlation for the lymphocytes CD19 and CD16NK and for adrenocorticotropic hormone.

CONCLUSIONS

The comparison between the psychometric and biochemical variables did not reveal any significant correlation among stress perception, daily satisfaction, and the biochemical parameters of stress.

Use of bedside sound generators by patients with tinnitus-related sleeping difficulty: which sounds are preferred and why?

CONCLUSIONS

Most tinnitus patients who have difficulty sleeping experience some improvement in sleep after short-term use of bedside sound generators (BSSGs), although this study does not allow conclusions to be drawn as to how much other factors contribute. Many patients seem to find BSSGs helpful in reducing autonomic arousal. Further research is needed, but these findings raise the possibility that the emotional effects of sound enrichment have an important role to play in improving sleep among tinnitus patients.

OBJECTIVES

This study investigated which sounds out of the options available on BSSGs are commonly chosen by patients and the reasons behind these choices. It also aimed to provide an indication as to whether BSSGs improve sleep quality in the short term.

PATIENTS AND METHODS

A consecutive series of 39 tinnitus clinic patients who made a subjective complaint of sleep disturbance took part in the study. All participants were given a Naturecare BSSG to use at night. The Pittsburgh Sleep Quality Index (PSQI) and a semi-structured interview were used as outcome measures.

RESULTS

Among the 35 participants who attended for follow-up there was a significant improvement in PSQI scores (p=0.001). 'Brook' and 'birds' were the most popular sounds, while 'white noise' proved the least popular. Most BSSG users listened to one sound only and most said that they chose their sound because of a pleasant emotional effect. A minority gave the quality of sound or its perceived effect on tinnitus as a reason for their choice.

Internet-Based Cognitive—Behavioral Self-Help Treatment of Tinnitus

The aim of this investigation was to evaluate Internet-based cognitive-behavioral therapy for tinnitus in a nonrandomized clinical effectiveness study with a sample of consecutive patients referred for psychological treatment ( N = 77). Results were calculated at a group level on an intention-to-treat basis and showed significant reductions of distress on the Tinnitus Reaction Questionnaire (P. H. Wilson, J. Henry, M. Bowen, & G. Haralambous, 1991), the Hospital Anxiety and Depression Scale (A. S. Zigmond & R. P. Snaith, 1983), and on the Insomnia Severity Index (C. H. Bastien, A. Vallières, & C. M. Morin, 2001). A 3-month follow-up showed that patients remained improved. The dropout rate was 30%. Treatment compliance, external referral to the treatment, and number of earlier treatments for tinnitus were associated with positive outcome. The number of e-mails between therapist and patient concerning treatment problems was associated with worse outcome. Internet-based cognitive-behavioral therapy holds some promise as a treatment modality for tinnitus. Future research should focus on further controlled evaluations of the treatment technique and evaluate the cost-effectiveness compared to other forms of tinnitus treatments.

Internet administration of the Hospital Anxiety and Depression Scale in a sample of tinnitus patients

OBJECTIVE

To administer and validate the Hospital Anxiety and Depression Scale (HADS) via the Internet to a sample of persons with tinnitus.

METHOD

The HADS was converted into a Web page and administered via the Internet to a sample of 157 persons with tinnitus who were recruited for participation in a treatment trial. Also included were the Tinnitus Reaction Questionnaire (TRQ) and the Anxiety Sensitivity Index (ASI). A clinical comparison sample (n=86) was also recruited who completed the same tests in a paper-and-pencil format.

RESULTS

Both the Internet and the paper-and-pencil version yielded comparable results in terms of psychometric properties. When using the cut-off of 11 points suggested by Zigmond and Snaith [Acta Psychiatr. Scand. 67 (1983) 361] a 25% (n=40) prevalence of probable anxiety and a 17% (n=27) prevalence of probable depression were found in the Internet group. In the clinic sample, the prevalence was only 15% for both anxiety and depression, suggesting that Internet administration might result in higher percentages. The HADS correlated with both tinnitus distress and anxiety sensitivity.

CONCLUSIONS

Internet administration of the HADS results in meaningful and valid data. Consistent with previous research anxiety and depression are common comorbid conditions in individuals with tinnitus, but norms should be developed for Internet based screening.