Article

Rapid assessment of tinnitus-related psychological distress using the Mini-TQ

Abstract and Figures

The aim of this study was to develop an abridged version of the Tinnitus Questionnaire (TQ) to be used as a quick tool for the assessment of tinnitus-related psychological distress. Data from 351 inpatients and 122 outpatients with chronic tinnitus were used to analyse item statistics and psychometric properties. Twelve items with an optimal combination of high item-total correlations, reliability and sensitivity in assessing changes were selected for the Mini-TQ. Correlation with the full TQ was >0.90, and test-retest reliability was 0.89. Validity was confirmed by associations with general psychological symptom patterns. Treatment effects indicated by the Mini-TQ were slightly greater than those indicated by the full TQ. The Mini-TQ is recommended as a psychometrically approved and solid tool for rapid and economical assessment of subjective tinnitus distress.
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Original Article
International Journal of Audiology 2004; 43:600–604
Rapid assessment of tinnitus-related
psychological distress using the Mini-TQ
Evaluación rápida del estrés psicológico relacionado
con el acúfeno mediante el uso de Mini-TQ
Wolfgang Hiller*
Gerhard Goebel
*Department of Clinical Psychology,
University of Mainz, Mainz,
Roseneck Centre of Behavioural
Medicine, Prien, Germany
Key Words
Tinnitus Questionnaire (TQ)
Mini-TQ
Assessment
Psychometric analysis
Tinnitus distress
Abstract
The aim of this study was to develop an abridged version
of the Tinnitus Questionnaire (TQ) to be used as a quick
tool for the assessment of tinnitus-related psychological
distress. Data from 351 inpatients and 122 outpatients
with chronic tinnitus were used to analyse item statistics
and psychometric properties. Twelve items with an opti-
mal combination of high item–total correlations, reliabil-
ity and sensitivity in assessing changes were selected for
the Mini-TQ. Correlation with the full TQ was 0.90,
and test–retest reliability was 0.89. Validity was con-
firmed by associations with general psychological symp-
tom patterns. Treatment effects indicated by the Mini-TQ
were slightly greater than those indicated by the full TQ.
The Mini-TQ is recommended as a psychometrically
approved and solid tool for rapid and economical assess-
ment of subjective tinnitus distress.
Sumario
El objetivo de este estudio fue desarrollar una versión
corta del Cuestionario del Acúfeno (TQ) para usarlo
como una herramienta rápida de evaluación del estrés
psicológico relacionado con el acúfeno. Se utilizaron los
datos de 351 pacientes internados y 122 pacientes exter-
nos con acúfeno crónico para analizar la estadística de
cada pregunta y sus propiedades psicométricas. Se selec-
cionaron para el Mini-TQ, 12 preguntas que tenían una
óptima combinación de elevada correlación, confiabili-
dad y sensibilidad para evaluar cambios. La correlación
con el TQ completo fue > 0.90 y la confiabilidad de com-
probación de la prueba fue del 0.89. Se validó la prueba
confirmando la asociación con patrones de síntomas psi-
cológicos. Los efectos del tratamiento indicados por el
Mini-TQ fueron ligeramente mayores que aquellos indi-
cados por el TQ completo. Se recomienda el Mini-TQ
como una herramienta psicométrica sólida, aprobada
para realizar una evaluación rápida y económica del
estrés producido por el acúfeno subjetivo.
Wolfgang Hiller
University of Mainz, Department of Clinical Psychology,
Staudingerweg 9, D-55099 Mainz, Germany
E-mail: hiller@mail.uni-mainz.de
Received:
September 11, 2003
Accepted:
January 9, 2004
There is strong evidence from the literature of the past 20 years
that the clinical picture of tinnitus is not strictly limited to oto-
logical considerations (Scott & Lindberg, 2000; Erlandsson &
Holgers, 2001). Patients may develop psychological complaints
of varying severity, especially when medical treatments fail and
the tinnitus has become chronic. Psychological complications
include annoyance resulting from the permanent awareness of
the noise, concentration problems, depression, anxiety and irri-
tability, sleep disturbances, and intense worrying. It is widely
recognized that reliable and valid instruments are needed to
describe these different facets and the degree of tinnitus-related
distress (McCombe et al, 2001).
In addition to clinical examinations, questionnaires are used
commonly for the examination of subjective complaints associ-
ated with tinnitus (Hallam et al, 1988; Erlandsson et al, 1992).
Patients respond to a set of questions or statements that are pre-
sented in a structured and standardized form. Well-developed
scales are easy to administer, yield reliable data, and allow a
valid interpretation of the patient’s current status. There are
strict psychometric criteria according to which the scientific and
clinical value of existing instruments can be judged (Anastasi &
Urbina, 1997). Different questionnaires are available that have
been specifically designed for the assessment of tinnitus-related
psychological complaints and symptoms. Table 1 shows the
scales that have been developed according to scientific standards
and are used in international research.
Although the instruments shown in Table 1 were developed in
different countries by independent working groups, they seem to
measure a very similar pattern of complaints and handicaps.
Baguley et al (2000) administered the Tinnitus Questionnaire
(TQ) and Tinnitus Handicap Inventory to the same sample of
patients, and found that the convergent validity of both instru-
ments was high, with total as well as subscale scores being signif-
icantly correlated. However, the value of subscales seems to be
limited, because there is no general agreement about how many
of them are needed and how they should be labelled. From our
perspective, it seems remarkable that most authors in this field
report only global indices of distress and no subscale results.
An unresolved problem with some questionnaires is the rela-
tively large number of items needed to determine a global dis-
tress measure. This is a disadvantage when the time available for
investigation is limited and other instruments need to be com-
pleted as well. For example, 40 of the 52 items of the TQ are
needed for computation of the total score (Hiller & Goebel,
1992). Therefore, after many years of working with the TQ, we
felt an increasing need for a quicker and more compact measure
601
Hiller/Goebel
Rapid assessment of tinnitus-related
psychological distress using the Mini-TQ
of overall tinnitus distress. Furthermore, we observed that
some items were of little value because they seemed to be char-
acteristic only for subgroups of patients or had low relevance for
usual clinical decisions.
In the present study, we attempted to develop an abridged
version of the TQ, with the primary goal of maintaining its
excellent psychometric qualities. This article describes this new
instrument, called the Mini-TQ, and provides data on reliability,
validity, sensitivity to change, and comparison with the full TQ.
Methods
Sample and procedure
To analyse scale characteristics, we used a large sample of 351 tin-
nitus patients treated at the Roseneck Centre for Behavioural
Medicine in Prien, Germany. This hospital is a research-oriented
unit affiliated to the Medical Faculty of the University of Munich.
It provides tertiary care services and forms part of the German
mental healthcare system. It includes a department that special-
izes in the treatment of chronic tinnitus according to the princi-
ples of cognitive behavioural therapy (CBT). The demographic
characteristics of the sample were as follows: 31.8% female, 68.2%
male, and mean age 47.4 years (SD9.8) (range 17–74 years). All
patients had chronic tinnitus (6 months), in most cases present
for 5–20 years. Major aetiological factors were history of sudden
hearing loss (about 40%), acoustical trauma or longstanding
noise exposure (about 40%), and Menière’s disease (about 10%).
Abnormal audiograms were found for about 70% of patients,
although hearing aids were indicated for only 20–25%.
The TQ was completed within 3 days of admission. As men-
tioned, this 52-item scale is a well-established instrument for the
assessment of the broad spectrum of tinnitus-related psychologi-
cal complaints. Areas of complaint include emotional and cog-
nitive distress, intrusiveness, auditory perceptual difficulties,
sleep disturbances, and associated somatic complaints. The total
TQ score indicates the general level of psychological and psy-
chosomatic distress. The TQ has been shown to be reliable and
valid in several previous studies (e.g. Hallam et al, 1988; Hiller
& Goebel, 1992; Hiller et al, 1994; Baguley et al, 2000).
Questions are answered as either true, partly true, or not true.
The total score was computed according to the coding criteria
published in our previous work (Hiller & Goebel, 1992). Post-
treatment TQ data were available for 220 patients in the above
sample.
Second sample for cross-validation
A second sample of 122 outpatients was used for cross-
validation of the results obtained from the main sample. These
patients were treated at the Psychological Institute of the
University of Mainz as part of a treatment programme evaluat-
ing CBT for chronic tinnitus patients (Haerkötter & Hiller, 1999;
Hiller & Haerkötter, unpublished data). All patients completed
the TQ before and after the treatments, which lasted for 4–10
weeks. Of the patients, 43.4% were female, and 56.6% male; the
mean age of the entire sample was 49.8 years (SD 13.7) (range
20–78 years). As in the first sample, all patients reported having
tinnitus for more than 6 months (28% for more than 5 years).
Medical diagnoses and hearing status were largely similar to
those for the inpatient sample.
Additional instruments
As general psychopathology is frequently found in chronic tinni-
tus patients, we employed the Hopkins Symptom Checklist
SCL-90R (Derogatis, 1983) as an external criterion to evaluate
the validity of the Mini-TQ.
Statistical methods
We used Pearson correlations to analyse the associations
between items and total scores, full TQ and Mini-TQ, and
tinnitus-related and general psychological complaints, and to
measure test–retest reliability. Reliability on item level will be
expressed by kappa (), a chance-corrected measure of agree-
ment between categorical variables. To evaluate the magnitude
of treatment effects, we calculated sample effect sizes (ESs)
according to the d statistic proposed by Cohen (1988).
Results
Item selection
To select items for the abridged questionnaire, we determined (1)
to what degree each item was associated with the overall
tinnitus-related distress (item–total correlations), (2) how often
each item was endorsed by tinnitus patients (item frequencies),
and (3) how dependably the contents were reported ( values
obtained in the test–retest study). We did not consider items of
the subscales ‘auditory perceptual difficulties’ and ‘somatic com-
plaints’. Based on these considerations, the 12 items shown in
Table 2 were chosen to constitute the Mini-TQ. Item–total cor-
relations and coefficients were generally good to high. Seven
items were taken from the intrusiveness and emotional distress
subscales (1, 2, 5, 6, 7, 9, 12), three from the cognitive distress
subscale (3, 10, 11) and one from the sleep disturbance subscale
(8). Item 4 had not previously been considered in TQ subscaling,
because the area of negative effects on social relationships is not
well represented in the item pool of the TQ. However, as this
item was found to have good psychometric properties and repre-
sents an important aspect of tinnitus-related distress, it was
decided to include it in the abridged questionnaire.
Table 1. Questionnaires to assess tinnitus-related distress
No. of No. of
Instrument items dimensions Authors
TQ Tinnitus Questionnaire 52 5 or 6 Hallam (1996); Hiller & Goebel (1992)
TRQ Tinnitus Reaction Questionnaire 26 4 Wilson et al (1991)
THQ Tinnitus Handicap Questionnaire 27 3 Kuk et al (1990)
THI Tinnitus Handicap Inventory 25 1–3 Newman et al (1996, 1998)
STSS Subjective Tinnitus Severity Scale 16 5 Halford & Anderson (1991)
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International Journal of Audiology, Volume 43 Number 10
Congruence between full TQ and Mini-TQ
Table 3 shows Pearson correlations between the Mini-TQ on one
hand, and the subscales and global score of the full TQ on the
other. Values 0.90 indicate extraordinarily high congruence of
the new 12-item version and the original TQ global score. It can
be seen that while our item selection resulted in good overlap
with the TQ subscales E, C and I, the correlations with the sub-
scales A and Sl are clearly lower.
Psychometric properties of the Mini-TQ
Table 4 shows high test–retest reliability and internal consistency
for the Mini-TQ, despite the small number of items. This result
is plausible, because a group of relatively homogeneous items
with good reliabilities on item level had been selected. It is
known that tinnitus-related complaints correlate moderately
with general psychological symptoms, which represents an
important aspect of validity. Table 5 displays the intercorrela-
tions of the abridged and full TQ with the subscales and scores
of the SCL-90R. It can be seen that the values are very similar.
Sensitivity of measures for the assessment of change
An important characteristic of a measure is its sensitivity for the
assessment of changes over time, e.g. when the course of a disor-
der or treatment effects are being evaluated. To analyse the
applicability of the Mini-TQ as an instrument for repeated mea-
surement, we compared treatment effects obtained for the same
samples with the full TQ and with the Mini-TQ. The inpatients
Table 2. Characteristics of the Mini-TQ items
Item–total Item frequency Test–retest
Items correlation
a
(true/partly true)
b
reliability
c
1. I am aware of the noises from the
moment I get up to the moment I sleep 0.56 60/27 0.49
2. Because of the noises I worry that there is
something seriously wrong with my body 0.39 33/32 0.57
3. If the noises continue my life will not be worth living 0.66 15/41 0.78
4. I am more irritable with my family
and friends because of the noises 0.58 40/39 0.54
5. I worry that the noises might damage my physical health 0.54 40/32 0.57
6. I find it harder to relax because of the noises 0.57 71/23 0.55
7. My noises are often so bad that I cannot ignore them 0.64 75/16 0.53
8. It takes me longer to get to sleep because of the noises 0.59 56/24 0.62
9. I am more liable to feel low because of the noises 0.65 55/31 0.62
10. I often think about whether the noises will ever go away 0.57 59/26 0.49
11. I am a victim of my noises 0.71 27/38 0.61
12. The noises have affected my concentration 0.66 61/31 0.63
a
Pearson correlation between item and full TQ global score according to Hiller & Goebel (1992), based on n 351.
b
Percentage of patients answering ‘true’/answering ‘partly true’, based on n 351.
c
Kappa (), based on n 60, from the study of Hiller et al (1994).
Table 3. Pearson correlations between TQ and Mini-TQ
Full TQ
ECE1CI A Sl So TQ
global
score
Mini-TQ
(inpatients) 0.93 0.84 0.93 0.80 0.51 0.65 0.48 0.93
Mini-TQ
(outpatients) 0.90 0.81 0.91 0.80 0.59 0.52 0.53 0.91
Based on n 351 (inpatients) and n 122 (outpatients).
Subscales of the TQ: E, Emotional distress; C, Cognitive distress; EC,
Emotional and cognitive distress; I, Intrusiveness; A, Auditory perceptual difficul-
ties; Sl, Sleep distrubances; So, Somatic complaints.
Table 4. Reliability and internal consistency of the Mini-TQ
Test–retest
a
n 60 0.89
Cronbachs’ n 349 0.87
(inpatients)
Cronbachs’ n 112 0.90
(outpatients)
a
Pearson correlation.
Table 5. Association with general psychopathology
SCL-90R scales Mini-TQ Full TQ
Somatization 0.30 0.32
Obsessive-compulsive 0.38 0.37
Interpersonal sensitivity 0.29 0.26
Depression 0.42 0.38
Anxiety 0.34 0.31
Hostility 0.27 0.26
Phobic anxiety 0.26 0.28
Paranoid ideation 0.29 0.28
Psychoticism 0.30 0.30
General symptomatic index (GSI) 0.40 0.39
Positive symptom total (PST) 0.37 0.36
Positive symptom distress index (PSDI) 0.41 0.38
Pearson correlations; based on n324.
603
Hiller/Goebel
Rapid assessment of tinnitus-related
psychological distress using the Mini-TQ
of the Roseneck Centre had been treated for 4–10 weeks with an
intense programme according to the principles of behavioural
medicine, including individual and group CBT, relaxation train-
ing, medical consultation, and physical and body-related thera-
pies (Goebel & Hiller, 1996). The outpatients at the University
of Mainz were treated according to a newly developed CBT pro-
gramme consisting of either 10 weekly sessions for severely dis-
tressed patients or four sessions for patients with only moderate
symptoms (Haerkötter & Hiller, 1999).
Table 6 summarizes the comparison between the full and
abridged TQ for decompensated inpatients with initial TQ
scores above 40 and for two outpatient subgroups with either
high (40) or moderate (40) levels of distress. Both measures
were able to identify significant improvements in all groups
(p 0.01). However, statistical significance does not guarantee
that the Mini-TQ is equally powerful in detecting differences
before and after treatment. We therefore calculated Cohens d
as an ES denoting a standardized difference between two means.
The results in Table 6 show that the Mini-TQ is equally, if not
slightly more, powerful than the full TQ for the measurement of
improvements during treatment.
The Mini-TQ was also able to differentiate more generally
between inpatients and outpatients. The entire inpatient group
improved from 15.8 (SD 5.7) to 13.0 (SD6.0), and the out-
patient group from 12.4 (SD5.3) to 8.7 (SD 5.8). The group
main effect for these data was significant in a repeated-measures
analysis of variance (df1, F 44.9, p 0.01).
Standardization and norms
The distribution of the Mini-TQ scores must be known if individ-
ual test results are to be interpreted properly. We therefore com-
puted cumulative percentages separately for our samples of
inpatients and outpatients (Table 7). The mean values (SDs)
were 15.4 (5.7) for inpatients and 12.6 (5.3) for outpatients.
Interpretation can depend on many variables, such as clinical set-
ting (e.g. private ENT practitioners, otological inpatient units,
tertiary care facilities for distressed tinnitus sufferers) or purpose
of investigation (e.g. treatment decision). However, our recommen-
dation is to consider patients scoring 1–7 as being compensated
(no clinically relevant distress due to the tinnitus), those scoring
8–12 as moderately distressed, those scoring 13–18 as severely dis-
tressed, and those scoring 19–24 as most severely distressed.
Discussion
This study was motivated by the desire to optimize the psycho-
metric assessment of tinnitus-related distress. We knew from our
long experience with the TQ that subscales are only rarely
analysed, and researchers as well as clinicians seem to be pri-
marily interested in a measure of overall distress. Although the
TQ is one of the best accepted questionnaires in the field of tin-
nitus research, its weaknesses are the large number of items (52)
and the fact that not all items are used to compute the total
score. Furthermore, there is an increasing need for short instru-
ments, because multiple scales are usually employed in research
Table 7. Norms for the Mini-TQ
Scores Inpatients Outpatients
(n 5351) (n 5122)
011
111
221
341
443
5510
6718
71121
81327
91730
10 21 34
11 26 43
12 31 48
13 35 55
14 41 62
15 46 67
16 52 78
17 58 81
18 66 85
19 71 89
20 76 93
21 84 94
22 91 95
23 96 98
24 100 100
Cumulative percentages.
Table 6. Use of the TQ and Mini-TQ to measure treatment effects
Before After
treatment treatment Significance Pre–Post
Subgroup Measure Mean (SD) Mean (SD) t-value ES
Inpatients TQ 40 Full TQ 59.7 (10.6) 50.3 (16.1) 8.99* 0.70
Mini TQ 18.4 (3.6) 15.2 (5.1) 8.92* 0.75
Outpatients TQ 40 Full TQ 54.7 (9.4) 41.7 (17.0) 6.85* 0.98
Mini-TQ 17.2 (3.3) 13.0 (5.6) 5.98* 0.94
TQ 40 Full TQ 24.9 (8.0) 16.6 (9.5) 8.01* 0.95
Mini TQ 9.0 (3.4) 5.5 (3.5) 7.73* 1.03
Based on n 156 (inpatients 40), n 54 (outpatients40) and n 68 (outpatients40). ES, effect size.
*p 0.01.
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International Journal of Audiology, Volume 43 Number 10
projects, and the patients’ willingness to accept large question-
naire batteries is limited.
The results of the present study are encouraging. The 12
items of the new Mini-TQ were selected according to strictly
defined psychometric criteria. We considered items only if they
were highly correlated with the general score and had proven to
be reliable. Another major criterion was their sensitivity for indi-
cating changes of symptomatology, because evaluating treat-
ment outcome represents a major application. Our analyses
confirmed that the Mini-TQ consists of a very homogeneous set
of items, with excellent values of reliability and internal consis-
tency. Furthermore, intercorrelations with measures of general
psychopathology were practically identical to those obtained
with the full TQ. We were also able to demonstrate that the new
measure was equally, or probably even slightly more, powerful in
the detection of improvements during inpatient and outpatient
treatments. In a last step, we provided norms for inpatients and
outpatients that may facilitate the interpretation of individual
scores for other users. However, as these were not patients usu-
ally seen in private ENT practices or audiological clinics, the
usefulness and validity of the Mini-TQ remains to be evaluated
in these settings.
To summarize, the development of the Mini-TQ represents a
further step towards the compact, quick and economical assess-
ment of subjective tinnitus distress. There are no recognizable
psychometric disadvantages as compared to the full TQ. We
therefore suggest that the full version should only be used if
there are special questions concerning the subscales, e.g. if there
is an interest in studying auditory perceptual difficulties or sleep
disturbances apart from general distress (Baguley et al, 2000).
The Mini-TQ is suitable for research and may help in the com-
parison of findings between countries. It can also be used in
everyday clinical practice, because the 12 selected items reflect
most central and characteristic aspects of tinnitus distress.
Although there are no general limitations, the scale is probably
more valuable for chronic tinnitus, since psychological distress
in acute patients may be temporary and of lower prognostic
value.
Appendix: the Mini-TQ
The purpose of this questionnaire is to find out whether the
noises in your ears/head have had any effect on your mood,
habits or attitudes. Please tick the answer that applies to you for
each statement.
1. I am aware of the noises from the moment I get up to the
moment I sleep
2. Because of the noises I worry that there is something seri-
ously wrong with my body
3. If the noises continue my life will not be worth living
4. I am more irritable with my family and friends because of
the noises
5. I worry that the noises might damage my physical health
6. I find it harder to relax because of the noises
7. My noises are often so bad that I cannot ignore them
8. It takes me longer to get to sleep because of the noises
9. I am more liable to feel low because of the noises
10. I often think about whether the noises will ever go away
11. I am a victim of my noises
12. The noises have affected my concentration
(Note: the response alternatives for each item are True, Partly
True, and Not True)
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... The study was approved by the Ethics Committee of the Faculty of Medicine of the University of Regensburg (Study approval number 15-101-0204). During registration, users were asked to fill-in two questionnaires: the Mini-Tinnitus Questionnaire (Hiller and Goebel, 2004) and the Tinnitus Sample Case History Questionnaire, TSCHQ (Langguth et al., 2007). In addition, users responded to a question about their worst tinnitus-related symptom. ...
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Background Tinnitus is a heterogeneous condition which may be associated with moderate to severe disability, but the reasons why only a subset of individuals is burdened by the condition are not fully clear. Ecological momentary assessment (EMA) allows a better understanding of tinnitus by capturing the fluctuations of tinnitus symptoms, such as distress and loudness, and psychological processes, such as emotional arousal, overall stress, mood, and concentration and how these variables interact over time. Whether any of those variables have an influence over the next day, that is, whether any of these variables are auto- or cross-correlated, is still unanswered.Objectives Assess whether behavioral and symptom-related data from tinnitus users from the TrackYourTinnitus (TYT) mobile app have an impact on tinnitus loudness and distress on subsequent days.Methods Anonymized data was collected from 278 users of the iOS or Android TYT apps between 2014 and 2020. Tinnitus-related distress, tinnitus loudness, concentration level, mood, emotional arousal, and overall stress level were assessed using either a slider or the Wong-Baker Pain FACES scale via a daily survey. Three modeling strategies were used to investigate whether tinnitus loudness and distress are affected by previous days symptoms or psychological processes: auto- and cross correlations, regressions with elastic net regularization, and subgrouping within group iterative multiple model estimation (S-GIMME).ResultsNo autocorrelation or cross-correlation was observed at the group level between the variables assessed. However, application of the regression models with elastic net regularization identified individualized predictors of tinnitus loudness and distress for most participants, with the models including contemporaneous and lagged information from the previous day. S-GIMME corroborated these findings by identifying individualized predictors of tinnitus loudness and distress from the previous day.DiscussionWe showed that tinnitus loudness and tinnitus distress are affected by the contemporaneous and lagged dynamics of behavioral and emotional processes measured through EMA. These effects were seen at the group, and individual levels. The relevance EMA and the implications of the insights derived from it for tinnitus care are discussed, especially considering current trends toward the individualization of tinnitus care.
... The studies using multi-item validated questionnaires to measure tinnitus distress, severity or impact on daily life were included (Table 1A). These include the Tinnitus Handicap Inventory (THI), the TQ, the mini Tinnitus Questionnaire (mTQ), the Tinnitus Functional index (TFI), the Tinnitus Handicap Questionnaire (THQ), the Tinnitus Primary Function Questionnaire (TPFQ), and the Tinnitus Reaction Questionnaire (TRQ) (20,21,(23)(24)(25)(26)28). ...
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Objectives In this systematic review, we aim to evaluate the evidence regarding the correlation between tinnitus distress and the severity of depressive symptoms in patients with chronic tinnitus. Also, the prevalence of clinically relevant depressive symptoms scores in patients with chronic tinnitus was evaluated. Methods We performed a systematic review in PubMed, EMBASE, and the Cochrane library in June 2021 using the terms “depression” and “tinnitus,” and their synonyms, following PRISMA guidelines. Studies were selected on relevance and critically appraised regarding risk of bias using the Newcastle–Ottowa Quality Assessment Scale. Results A total of 1,912 articles were screened on title and abstract after the removal of the duplicates. Eventually, 33 (1.5%) articles were included for the final analysis. Only cross-sectional cohort studies and case–control studies with a low level of evidence and a high risk of bias due to the study design and patient selection were found. Statistically significant correlations between the experienced tinnitus distress and depressive symptoms were reported in 31 out of 33 studies. Clinically relevant depression scores had a prevalence of 4.6–41.7%. Conclusions In this systematic review, in which mostly cross-sectional studies were included, a statistically significant correlation was found between the experienced tinnitus distress and the reported severity of symptoms of depression in patients with chronic tinnitus. A wide range of clinically relevant depression scores were reported in included studies. Due to the high risk of bias of included studies it is not possible to provide a definite answer on the existence of this relationship. Future population-based studies are necessary to provide more clarity.
... In two cases, both ears were nearly identical, so testing was done for both sides, i.e., we tested 26 individual noise parameters in 24 patients. To exclude patients with decompensated tinnitus we asked everyone to fill out the mini-tinnitus questionnaire miniTQ12 (Hiller and Goebel, 2004); only patients with a maximal severity index (SI) of three (of four) were included in the study. Note that in this study no patient had to be excluded because of this criterion. ...
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Recently, we proposed a model of tinnitus development based on a physiological mechanism of permanent optimization of information transfer from the auditory periphery to the central nervous system by means of neuronal stochastic resonance utilizing neuronal noise to be added to the cochlear input, thereby improving hearing thresholds. In this view, tinnitus is a byproduct of this added neuronal activity. Interestingly, in healthy subjects auditory thresholds can also be improved by adding external, near-threshold acoustic noise. Based on these two findings and a pilot study we hypostatized that tinnitus loudness (TL) might be reduced, if the internally generated neuronal noise is substituted by externally provided individually adapted acoustic noise. In the present study, we extended the data base of the first pilot and further optimized our approach using a more fine-grained adaptation of the presented noise to the patients’ audiometric data. We presented different spectrally filtered near-threshold noises (−2 dB to +6 dB HL, 2 dB steps) for 40 s each to 24 patients with tonal tinnitus and a hearing deficit not exceeding 40 dB. After each presentation, the effect of the noise on the perceived TL was obtained by patient’s response to a 5-scale question. In 21 out of 24 patients (13 women) TL was successfully subjectively attenuated during acoustic near-threshold stimulation using noise spectrally centered half an octave below the individual’s tinnitus pitch (TP). Six patients reported complete subjective silencing of their tinnitus percept during stimulation. Acoustic noise is able to reduce TL, but the TP has to be taken into account. Based on our findings, we speculate about a possible future treatment of tinnitus by near-threshold bandpass filtered acoustic noise stimulation, which could be implemented in hearing aids with noise generators.
... There are no objective tests to determine the existence or severity of tinnitus, but there are many different standardized questionnaires to assess quality of life and annoyance related to tinnitus. Some of the most popular questionnaires are the tinnitus handicap inventory (THI) [10,11], the tinnitus reaction questionnaire (TRQ) [12], the tinnitus questionnaire (TQ), the tinnitus functional Index (TFI) [13], and the mini-TQ [14]. ...
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Background: Tinnitus is a heterogeneous condition. The aim of this study as to compare the online and hospital responses to the Spanish version of European School for Interdisciplinary Tinnitus Research screening-questionnaire (ESIT-SQ) in tinnitus individuals by an unsupervised age clustering. Methods: A cross-sectional study was performed including 434 white Spanish patients with chronic tinnitus to assess the demographic and clinical profile through the ESIT-SQ, with 204 outpatients and 230 individuals from an online survey; a K-means clustering algorithm was used to classify both responses according to age. Results: Online survey showed a high proportion of Meniere's disease (MD) patients compared to both the general population and the outpatient cohort. The responses showed statistically significant differences between groups regarding education level, tinnitus-related hearing disorders (MD, hyperacusis), sleep difficulties, dyslipidemia, and other tinnitus characteristics, including duration, type of onset, the report of mitigating factors and the use of treatments. However, these differences were partially confirmed after adjusting for age. Conclusions: Self-reported tinnitus surveys are a low confidence source for tinnitus phenotyping. Additional clinical evaluation is needed for tinnitus research to reach the diagnosis. Age-based cluster analysis might help to better define clinical profiles and to compare responses in ESIT-SQ among subgroups of patients with tinnitus.
... The Tinnitus Functional Index (TFI, [37]) was defined as the primary outcome for the trial (see also ClinicalTrials.gov; NCT03957122) and had to be filled out at screening, baseline, treatment end, and follow-up visits together with the following further questionnaires: the Tinnitus Handicap Inventory (THI, [38,39]), the Mini Tinnitus Questionnaire (Mini-TQ, [40]), the Major Depression Inventory (MDI, [41]), the World Health Organization-Quality of Life instrument (WHOQOL-BREF) covering the four domains physical health, psychological, social relationships, and environment [42]. Beyond that, participants had to rate the loudness of their tinnitus (0-not at all loud; 10-extremely loud), the tinnitus-induced discomfort (0-no discomfort; 10-severe discomfort), annoyance (0-not at all annoying; 10-extremely annoying), unpleasantness (0-not at all unpleasant; 10-extremely unpleasant) as well as the possibility to ignore their tinnitus (0-very easy to ignore; 10-impossible to ignore) on Visual Analog Scales (VAS). ...
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Background: Personalization of repetitive transcranial magnetic stimulation (rTMS) for tinnitus might be capable to overcome the heterogeneity of treatment responses. The assessment of loudness changes after short rTMS protocols in test sessions has been proposed as a strategy to identify the best protocol for the daily treatment application. However, the therapeutic advantages of this approach are currently not clear. The present study was designed to further investigate the feasibility and clinical efficacy of personalized rTMS as compared to a standardized rTMS protocol used for tinnitus. Methods: RTMS personalization was conducted via test sessions and reliable, sham-superior responses respectively short-term reductions in tinnitus loudness following active rTMS protocols (1, 10, 20 Hz, each 200 pulses) applied over the left and right temporal cortex. Twenty pulses at a frequency of 0.1 Hz served as a control condition (sham). In case of a response, patients were randomly allocated to ten treatment sessions of either personalized rTMS (2000 pulses with the site and frequency producing the most pronounced loudness reduction during test sessions) or standard rTMS (1 Hz, 2000 pulses left temporal cortex). Those participants who did not show a response during the test sessions received the standard protocol as well. Results: The study was terminated prematurely after 22 patients (instead of 50 planned) as the number of test session responders was much lower than expected (27% instead of 50%). Statistical evaluation of changes in metric tinnitus variables and treatment responses indicated only numerical, but not statistical superiority for personalized rTMS compared to standard treatment. Conclusions: The current stage of investigation does not allow for a clear conclusion about the therapeutic advantages of personalized rTMS for tinnitus based on test session responses. The feasibility of this approach is primarily limited by the low test session response rate.
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This is a reprint of articles from the Special Issue published online in the open access journal Brain Sciences (ISSN 2076-3425) (available at: www.mdpi.com/journal/brainsci/special issues/Stimulation Neuroplasticity II).
Article
Objective Different domains of tinnitus-related distress can be assessed by self-report questionnaires, such as the original 52-item version of the Tinnitus Questionnaire (TQ). Short forms of the TQ allow a more rapid assessment. For this purpose, a new 15-item short form (Mini-TQ-15) has been previously developed. In the present retrospective cohort study, we aimed to compare construct validity of the Mini-TQ-15 and the original TQ. Methods Data of 7112 patients with chronic tinnitus that filled out the German 52-item version of the TQ at the Tinnitus Center at Charité University Hospital Berlin, Germany were retrospectively analyzed. 1409 of the 7112 patients completed additional psychological tests (ADS-L, BSF, PHQ, ACSA, SWOP) before starting therapy. Data of these 1409 patients with higher tinnitus distress on average were included in the present study. We compared convergent and discriminant validity of the TQ and the Mini-TQ-15 by calculating Spearman's rank correlation between their different factors and the results of further self-report questionnaires. Results The factor emotional and cognitive distress of the original TQ and of the Mini-TQ-15 showed specific high correlations with depression scales (correlation coefficients between 0.50 and 0.60) and considerably lower correlations with the other scales. Conclusion Results of the present study indicate good convergent and discriminant validity of the Mini-TQ-15 and of the original TQ. The three factorial Mini-TQ-15 represents a promising short version with good construct validity for a rapid and differentiated assessment of tinnitus-related distress.
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Background Tinnitus is a heterogeneous condition associated with moderate to severe disability, but the reasons why only a subset of individuals is burdened by the condition are not fully clear. Ecological momentary assessment (EMA) allows a better understanding of tinnitus by allowing individualized models and by capturing the fluctuations of tinnitus symptoms and other behavioral dynamics as they occur, and therefore minimizing the risk of recollection bias. The TrackYourTinnitus (TYT) mobile app provides a platform for collecting ecologically valid time series data from tinnitus users and can be used to address questions like how mood, concentration, tinnitus distress, or loudness relate over time. Whether any of those variables have an influence over the next day, that is, whether any of these variables are auto- or cross-correlated, is still unanswered. Objectives Assess whether behavioral and symptom-related data from tinnitus users from the TYT app auto- and cross-correlate in different time lags, both within and between individuals. Methods Anonymized data was collected from 278 users of the iOS or Android TYT apps between 2014 and 2020. Tinnitus-related distress, tinnitus loudness, concentration level, overall mood, emotional arousal, and overall stress level were assessed using a 10-point visual analog scale via a daily survey. Auto- and cross-correlations were calculated for participants who used the app for at least 10 consecutive days. Lagged cross-correlation was used to investigate the dynamics of each of these variables over time at the group level, followed by linear regression with elastic net regularization for each user. Additionally, subgrouping within group iterative multiple model estimation (S-GIMME) was used to model the behavioral dynamics at the group, subgroup, and individual levels with data collected from 32 users. Results No autocorrelation or cross-correlation was observed at the group level between the variables assessed. However, application of the regression models with elastic net regularization identified individualized predictors of tinnitus loudness and distress for most participants, with the models including contemporaneous and lagged information from the previous day. The finding that a subset of users experienced lagged and contemporaneous dynamics was corroborated by the models from S-GIMME. The models had adequate fits, with both contemporaneous and lagged coefficients obtained for most individuals. Two subgroups were identified, the first consisting of users where both contemporaneous and lagged effects were observed, and a second subgroup consisting of users whose dynamics were mainly of contemporaneous effects. Discussion We showed that tinnitus loudness and tinnitus distress are affected by the contemporaneous and lagged dynamics of behavioral and emotional processes measured through EMA. These effects were seen at the group, subgroup, and individual levels. The relevance EMA and the implications of the insights derived from it for tinnitus care are discussed, especially considering current trends towards the individualization of tinnitus care.
Thesis
Die vorliegende retrospektive Studie konnte eine Vielzahl an Einflussfaktoren auf den chronischen Tinnitus herausstellen und untersuchte deren genaue Auswirkung auf die jeweiligen Hörschwellen. Dabei wurden nahezu alle anamnestisch erfassbaren Daten erhoben und in die Dissertation eingepflegt. Es wird gezeigt, dass gerade Erkrankungen aus dem Bereich der Endokrinen, Ernährungs- und Stoffwechselkrankheiten sowie Erkrankungen des Kreislaufsystems eine besonders starke Korrelation mit Hörschwellenveränderungen beim Vorhandensein eines chronischen Tinnitus aufweisen. Unter der Berücksichtigung der unterschiedlichen Einflussfaktoren ergeben sich Konstellationen, welche ein vermeintlich erhöhtes Risikoprofil für besonders betroffene Patienten erahnen lassen. Personen mit ausschließlich einer zusätzlichen Erkrankung aus dem Bereich der Endokrinen, Ernährungs- und Stoffwechselkrankheiten zeigen in Kombination mit folgenden Parametern besonders große Hörschwellenverluste: Altersgruppe 40 bis 60 Jahre, Geschlecht weiblich, keine berufliche Lärmexposition, klinisch relevante Heredität der Ohrsymptomatik, beidseitig vorhandene Hörgeräte, Tinnitustyp in Form eines reinen Sinustons. Personen mit ausschließlich einer zusätzlichen Erkrankung aus dem Bereich des Kreislaufsystems zeigen in Kombination mit folgenden Eigenschaften besonders große Hörschwellenverluste: Altersgruppe über 60 Jahre, Geschlecht männlich, keine berufliche Lärmexposition, uni- oder bilateral vorhandene Hörgeräte, Tinnitustyp in Form eines Schmalbandrauschens.
Article
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Two new questionnaires were devised to investigate dimensions of complaint about tinnitus. Following a factor analysis of data provided by a sample of tinnitus patients who were administered the first questionnaire, the second questionnaire was developed. This included questions concerning coping attitudes and beliefs about tinnitus. The results of the two analyses were similar and they indicated the presence of three main dimensions of complaint (emotional distress, auditory perceptual difficulties, and sleep disturbance). However several smaller factors suggested that complaint was more complex than originally predicted. The second questionnaire successfully discriminated complaining from non-complaining patients.
Article
Dimensions of psychological complaints due to chronic and disabling tinnitus were investigated by means of the Tinnitus Questionnaire (TQ), administered to a sample of 138 tinnitus sufferers who had been admitted to a psychosomatic hospital. Factor analysis revealed that tinnitus-related patterns of emotional and cognitive distress, intrusiveness, auditory perceptual difficulties, sleep disturbances, and somatic complaints can be differentiated. Cognitive distortions and inappropriate attitudes towards the tinnitus and it's personal consequences were found to be highly intercorrelated forming a subgroup within a broader and more general distress factor. The stability of the factor solution obtained was examined by systematically varying the number of factors to be extracted. Based on the results of this method, scales are proposed for the questionnaire which can be used in clinical and scientific work to specifically assess major areas of tinnitus-related distress and their degree of severity. Implications for a further evaluation of the instrument are discussed.
Article
Beliefs and attitudes towards tinnitus have been found to play an important role in the process of rehabilitation. The relationship between audiological, psychological and psychosomatic factors (self-assessment of vertigo and headache and the perceived severity of tinnitus) was investigated in a clinical population of 163 subjects. Audiological descriptives comprised pure-tone average (dB HL), etiology of hearing loss, duration of tinnitus and tinnitus localisation. Perceived severity of tinnitus was assessed with a questionnaire focusing on tinnitus impact on aspects of quality of life, concentration and sleep. A 28-item handicap and support questionnaire was used and factor analysed, resulting in three factors: perceived attitudes, social support and disability/handicap. Tinnitus severity was significantly related to perceived attitudes. The influence of social support on tinnitus severity did not seem to be crucial. The results showed that significantly more women than men complained about vertigo. Unilateral tinnitus localisation was also more prevalent in females. The subjects with multiple tinnitus localisations were older and had significantly more sleep disturbance than subjects with tinnitus localized to the ears only. In accordance with previously reported observations, the frequency of headaches was strongly correlated with the severity of tinnitus.
Article
The development of the Tinnitus Reaction Questionnaire (TRQ), a scale designed to assess the psychological distress associated with tinnitus, is described. Psychometric analyses of the TRQ are examined with a total of 156 subjects in three separate samples. The results indicate very good test-retest reliability (r = .88) and internal consistency (Cronbach's alpha = .96). Factor analysis yielded four factors that were interpreted as General Distress, Interference, Severity, and Avoidance. Moderate to high correlations were found between the TRQ and clinician ratings (r = .67) and self-report measures of anxiety and depression (r = .58-.87), but a low correlation was found with neuroticism (r = .27). It is concluded that the TRQ provides a useful index of distress related to tinnitus for subject selection and clinical assessment and has potential as a measure of change in coping ability.
Article
Tinnitus is discussed, with particular reference to the problem of assessing severity. The authors argue that tinnitus severity can only usefully be determined by measuring the impact of tinnitus on an individual, and therefore propose a scale to estimate severity in these terms. Data presented on 112 members of a tinnitus self-help group, demonstrated the reliability of a Subjective Tinnitus Severity Scale (S.T.S.S.), with a coefficient alpha of 0.84. This indicates a high degree of internal consistency, i.e.: statistically this scale is measuring aspects of a single dimension. The validity was established in a separate sample of 30 clinic attenders, where mean S.T.S.S. scores were found to correlate highly with two independent clinical ratings of severity (r2 = 0.76, p less than 0.001, and r2 = 0.73, p less than 0.001). Additionally, in these patients S.T.S.S. scores were significantly associated with several audiometric variables, although the correlations were of low magnitude.
Article
The psychometric properties of a tinnitus handicap questionnaire are reported. There were two phases in this study. In Phase I, 87 questions were administered to 100 tinnitus patients. From their responses, 59 items that were either redundant, insensitive, or had low item-total correlations were eliminated. In Phase II, the resulting 27-item questionnaire was administered to 319 patients. Fifty-three of these patients also completed psychological and psychophysical measures that were used to validate the questionnaire. A factor analysis of patients' responses revealed a three-factor structure. These three factors appeared to reflect the physical, emotional, and social consequences of tinnitus (Factor 1), hearing ability of the patient (Factor 2), and the patients' view of tinnitus (Factor 3). Although the 27-item questionnaire had high internal consistency reliability and validity as reflected by correlations with life satisfaction and depression scales, it is recommended that only the items on the Factor 1 and the Factor 2 subscales be scored because of the low internal consistency reliability of the Factor 3 subscale. This questionnaire can be used to compare a patient's tinnitus handicap with the norm, identify specific areas of handicaps, and to monitor a patient's progress with particular treatment programs.
Article
• Conventional vestibulometric techniques are inadequate for quantifying the impact of dizziness on everyday life. The 25-item Dizziness Handicap Inventory (DHI) was developed to evaluate the selfperceived handicapping effects imposed by vestibular system disease. The development of the preliminary (37 items) and final versions (25 items) of the DHI are described. The items were subgrouped into three content domains representing functional, emotional, and physical aspects of dizziness and unsteadiness. Cronbach's α coefficient was employed to measure reliability based on consistency of the preliminary version. The final version of the DHI was administered to 106 consecutive patients and demonstrated good internal consistency reliability. With the exception of the physical subscale, the mean values for DHI scale scores increased significantly with increases in the frequency of dizziness episodes. Test-retest reliability was high. (Arch Otolaryngol Head Neck Surg. 1990;116:424-427)