The International Tinnitus Journal

The International Tinnitus Journal

Official Journal of the Neurootological and Equilibriometric Society
Official Journal of the Brazil Federal District Otorhinolaryngologist Society

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ISSN: 0946-5448

Volume 23, Issue 2 / November 2019

Research Article Pages:103-107
10.5935/0946-5448.20190018

Psychosocial consequences of the loudness of tinnitus

Authors: Henk M Koning

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Abstract

Introduction: Tinnitus distress is associated with the perceived loudness of the tinnitus. Objectives: To evaluate the psychosocial problems in tinnitus patients and to explore any relation with the tinnitus loudness.

Design: From all patients who were treated in our clinic from January 2017 to September 2019 for their tinnitus, patients chart and a questionnaire with the psychosocial variables were studied retrospectively.

Results: Almost half of the tinnitus patients could not withstand their tinnitus and they were faced with disturbed concentration and feeling depressed. Psychosocial problems were related to the maximal loudness of the tinnitus. If the perceived maximal loudness of the tinnitus was above 73 millimetre on the visual analogue scale the prevalence of psychosocial problems raised. If it was above 83 millimetre the majority of these patients had psychosocial problems.

Conclusion: Psychosocial problems were related to the maximal loudness of the tinnitus. We recommend patients suffering from severe tinnitus distress that therapy should be aimed at a reduction of the maximal loudness of tinnitus to less than 73 mm on the visual analogue scale.

Keywords: Tinnitus, tinnitus distress, tinnitus loudness, visual analog scale, psychological disorder


 

Introduction

Tinnitus can cause distress, sleep problems, and reduced quality of life[1-3]. A minority of the tinnitus patients are subjected to serious psychosocial consequences of their tinnitus4. Tinnitus distress is associated with the perceived tinnitus loudness and further research is warranted[2-4]. This study was performed to evaluate the psychosocial problems in tinnitus patients and to explore any relation with tinnitus loudness.

Materials and Methods

Following approval of the Medical research Ethics Committees United (Nieuwegein, the Netherlands), all patients who were treated in our clinic in the period from January 2017 to September 2019 for their tinnitus were retrospectively studied. Information obtained was medical data and the psychosocial survey. The survey had the following items (“Are your tinnitus acceptable?”, “Is your concentration disturbed?”, “Are you capable to resist your tinnitus?”, “Are you feeling depressed?”, “Are you having fear”, and “Are you having anger?”). The response for each question could be “none”, “slight”, “moderate”, or “always”.

Data assessment

The data obtained from each patient were age, sex, the perceived tinnitus loudness measured by the visual analogue scale (VAS), and the outcome of the psychosocial survey. VAS of tinnitus loudness are 10 cm lines between “no tinnitus” and “unbearable loud”. The tinnitus patient is requested to indicate on the line the mean, minimal and maximal loudness of their tinnitus. The distance (millimetre) on the 10 cm line is the score. The items of the survey for the psychosocial consequences of tinnitus can be answered “none” (0), “slight” (1), “moderate” (2), or “good” (3). A score of 2 or more indicated for the acceptance of tinnitus and for the capability to resist their tinnitus as normal. A score of 2 or more for concentration, depression, fear and anger was considered as disturbed. Data from the audiogram at the dominant side of the tinnitus was used for analysis. In cases of bilateral tinnitus with equal intensity, the mean of the audiogram was computed and used.

Statistical methods

For statistical analysis, we used Minitab 16 (Minitab Inc., State College, PA, USA). Multivariate statistical analysis was performed for the correlation of tinnitus loudness with the results of the psychosocial survey. A value of p<0.05 was considered statistically significant.

Results

In the period from January 2017 to September 2019, there were 202 tinnitus patients treated in our clinic. The description of the patients is given in Table 1. Almost half of the patients were incapable to resist their tinnitus. Their concentration was disturbed and felt depressed. Fear or anger was reported by only a minority of the tinnitus patients. In Table 2, the items of the psychosocial survey were compared with the tinnitus loudness. The maximal tinnitus loudness was statistical significant correlated to all items of the psychosocial questionnaire, in contrast to the minimal tinnitus loudness. The mean loudness of tinnitus showed only a significant correlation with the “acceptance of tinnitus” and to the “capability to resist their tinnitus”. The variation between minimal and maximal loudness was statistical significant related to “disturbed concentration”, “capability to resist their tinnitus”, “feeling depressed”, and “having fear”. Multivariate statistical analysis conducted to see which levels of the maximal loudness and which levels of variation between minimal and maximal loudness of tinnitus are associated with changes in the acceptance of tinnitus (Table 3). If the maximal loudness of the tinnitus increased above 73 millimetre on the visual analogue scale the prevalence of psychosocial problems raised. If it was above 83 millimetre the majority of the patients had psychosocial problems. The difference between minimal and maximal loudness of tinnitus associated with a change in the groups are presented in Table 4. If the variation between the minimal and maximal loudness of tinnitus was above 41 millimetres the vast majority of patients had disturbed concentration and were feeling depressed.

Contents Prevalence Median Q1 – Q3
Age (year) - 57 50.0- 64.3
Gender (male) 57% - -
Hearing loss (dB) at:
  250 Hz - 15 8.0 – 25.0
  500 Hz - 15 5.0 – 25.0
  1 KHz - 15 10.0 – 30.0
  2 KHz - 20 10.0 – 35.0
  4 KHz - 40 20.0 – 55.0
  8 KHz - 50 29.0 – 66.5
Loudness tinnitus (VAS; mm):
   Mean   68 50.0 – 81.0
   Minimal   42 20.0 – 62.0
   Maximal   84 69.8 – 95.0
Tinnitus not acceptabel 53% - -
Concentration disturbed 60% - -
Tinnitus not to resist 46% - -
Feeling depressed 42% - -
Having fear 32% - -
Having anger 18% - -
dB: decibel; Hz: Hertz; KHz: Kilohertz;Q1 – Q3: Inter-Quartile Range; VAS: Visual Analogue Scale; mm: millimetre

Table 1: Clinical characteristics of the patients with tinnitus.

Tinnitus Acceptable No (n=65) Yes (n=57)    
Loudness tinnitus (VAS; mm) Mean SEM Mean SEM P-value  
  Mean 68.8 3.4 57 3.4 0.016 Sign.
  Minimal 45.5 4.3 41.7 3.5 0.493  
  Maximal 84.3 3.1 73 2.9 0.004 Sign.
  Difference Maximal and Minimal 32.7 3.3 40.2 4.1 0.155  
Concentration Disturbed Yes (n=75) No (n=49)    
Loudness tinnitus (VAS; mm) Mean SEM Mean SEM P-value  
  Mean 65.3 3.6 59.2 3.8 0.224  
  Minimal 42.5 3.6 44.2 4.3 0.765  
  Maximal 83.6 2.3 71.3 3.3 0.003 Sign.
  Difference Maximal and Minimal 43.3 3.5 27.4 3.6 0.002 Sign.
Can resist their tinnitus No (n=54) Yes (n=63)    
Loudness tinnitus (VAS; mm) Mean SEM Mean SEM P-value  
  Mean  69.3 3.6 56.4 3.3 0.010 Sign.
  Minimal 45.7 4.4 40.2 3.5 0.332  
  Maximal 88.2 1.5 70.5 3.1 0.000 Sign.
  Difference Maximal and Minimal 44 4.1 31.3 3.4 0.020 Sign.
Feeling Depressed Yes (n=51) No (n=71)    
Loudness tinnitus (VAS; mm) Mean SEM Mean SEM P-value  
  Mean 65 3.7 60.7 3.3 0.39  
  Minimal 39.0 4.0 45.4 3.7 0.243  
  Maximal 85.0 2.4 73.8 2.9 0.003 Sign.
  Difference Maximal and Minimal 48.5 3.9 28.7 3.2 0.000 Sign.
Having Fear Yes (n=39) No (n=84)    
Loudness tinnitus (VAS; mm) Mean SEM Mean SEM P-value  
  Mean 63 4.3 62.8 3 0.964  
  Minimal 37.3 4.4 45.9 3.4 0.128  
  Maximal 85.3 2.9 75.7 2.5 0.014 Sign.
  Difference Maximal and Minimal 47.8 4.7 31.7 3 0.005 Sign.
Having Anger Yes (n=22) No (n=101)    
Loudness tinnitus (VAS; mm) Mean SEM Mean SEM P-value  
  Mean 68.8 6.6 61.6 2.7 0.322  
  Minimal 44.4 8.5 43.4 2.9 0.907  
  Maximal 87.4 2.6 76.8 2.3 0.004 Sign.
  Difference Maximal and Minimal 41.6 7.2 35.3 2.8 0.425  
Note dB decibel; Hz Hertz; KHz Kilohertz; SEM Standard Error of the Mean; Sign Significant; Prev Prevalence; VAS Visual Analogue Scale; mm millimetre.

Table 2:  The results of the comparison of the results of the survey for the psychosocial consequences of tinnitus with the parameters of the loudness of tinnitus.

Maximal loudness tinnitus (VAS; mm) Less than 73 73 -77 78 - 83 More than 83 P-value  
Not acceptable 31% 60% 33% 65% 0.009 Sign.
Concentration disturbed 34% 60% 60% 77% 0.001 Sign.
Feeling depressed 28% 40% 27% 58% 0.026 Sign.
Cannot resist their tinnitus 16% 40% 40% 64% 0.000 Sign.
Having Fear 19% 40% 20% 43% 0.070  
Having Anger 6% 20% 20% 23% -  

Table 3: The levels of the maximal loudness of the tinnitus and the results of the survey for the psychosocial consequences of tinnitus.

Maximal - Minimal loudness tinnitus (VAS; mm) Less than 31 31-36 37-41 More than 41 P-value  
Not acceptable 43% 50% 25% 61% 0.209  
Concentration disturbed 46% 50% 50% 79% 0.011 Sign.
Feeling depressed 27% 33% 38% 64% 0.006 Sign.
Cannot resist their tinnitus 33% 33% 38% 59% 0.106  
Having Fear 24% 33% 25% 44% 0.269  
Having Anger 13% 0% 13% 24% -  

Table 4:  The levels of the gap between maximal and minimal loudness of the tinnitus and the results of the survey for the psychosocial consequences of tinnitus.

Discussion

In this group of tinnitus sufferers, almost half of the patients had no capability to resist their tinnitus and found their tinnitus not acceptable. Their concentration was hampered and they felt depressed. These psychosocial problems were related to the maximal loudness of the tinnitus. If the perceived maximal loudness of the tinnitus increased above 73 millimetre on the visual analogue scale the prevalence of psychosocial problems raised. If it was above 83 millimetre the majority of the patients had psychosocial problems.

It has been suggested that at least two distinct brain networks are involved in tinnitus[5]. One network is associated with the distress caused by tinnitus, and the other network reflects tinnitus loudness[6]. The anterior cingulate/insula, parahippocampus, and auditory cortex are functioning within the loudness network[7]. The inadequate coping in tinnitus patients is thought to be related to the left dorsolateral prefrontal cortex8. In normal conditions, there is no intercommunication between distress and loudness networks. Only in distressed patients, there is interaction between both networks[5]. It is possible that the interaction between those two networks depends on the level of the maximal tinnitus loudness. In our study, a maximal loudness of tinnitus of 73 mm on the VAS and/or variation between maximal and minimal loudness above 41 mm on the VAS was found to induce tinnitus distress in considerably more patients.

Exposure to intense sound can raise the activity of central auditory neurons for a longer period[9]. Overstimulation induce neural plasticity not only in the auditory nervous system but also in other parts of the central nervous system[10]. It may be possible that if perceived maximal loudness of tinnitus exceeds a certain threshold also neural plasticity in the tinnitus distress network will occur.

Therapy of tinnitus should be focused on a reduction of the tinnitus loudness, commonly assessed with a numeric rating scale[11] Also, our study indicate that the lowering the maximal tinnitus loudness will have a direct impact on the improvement in patient’s wellbeing. When the maximal tinnitus loudness from above 83 mm is diminished to less than 73 mm, the incapability to resist their tinnitus decreased from 64% to 16% and feeling depressed from 58% to 28%.

Consequently, physicians can use perceived tinnitus loudness to identify the ones at risk for tinnitus distress12. Also, the use of perceived tinnitus loudness during therapy can be used as an indication to see whether the measures taken are effective. The perceived tinnitus loudness are simple and easy to measure and the results are easy to interpret. Therefore, we conclude that the three tinnitus self-rating scales (mean, minimal and maximal) are a valuable additive for the patient's current tinnitus status.

Our retrospective study has limitations. A prospective follow-up study is a logic sequel to confirm these results and endorse the conclusions. Also, we used a simple questionnaire to reflect the use of these questions in clinical practice. In a follow-up study, more extensive questionnaires could eventually give more extensive information of the psychosocial consequences of tinnitus.

Conclusion

Psychosocial problems were related to the maximal loudness of the tinnitus. We recommend patients suffering from severe tinnitus distress that therapy should be aimed at a reduction of the maximal loudness of tinnitus to less than 73 mm on the visual analogue scale.

Conflict of Interest


Department of Pain Therapy and Pain Clinic de bilt, Netherlands

Send correspondence to: Henk M Koning, Department of Pain therapy and Pain clinic de bilt, Netherlands Email: [email protected] Phone: +0031302040753

Citation: Henk M Koning. Psychosocial consequences of the loudness of tinnitus.Int Tinnitus J. 2019;23(2): 103-107.

Paper submitted to the ITJ-EM (Editorial Manager System) on November 06, 2019; and accepted on November 20, 2019.