Psychosomatics 41:347-352, August 2000
© 2000 The Academy of Psychosomatic Medicine
Psychological Profile and Somatic Complaints Between Help-Seeking and Non-Help-Seeking Tinnitus Subjects
Berit Scott, Ph.D., and
Per Lindberg, Ph.D.
Received July 12, 1999; revised December 20, 1999; accepted January 12, 2000. From the Department of Psychology, Uppsala University, Sweden, and the Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Sweden. Address reprint requests to Dr. Scott, Dept. of Psychology, Uppsala University, Box 1225, S-751 42 Uppsala, Sweden; email: berit.scott{at}psyk.uu.se
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ABSTRACT
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In a three-group comparison, a tinnitus help-seeking group (TH) was compared on a number of different psychological measures with a tinnitus non-help-seeking group (TNH) and matched control subjects. The authors address the difference in reports of somatic complaints between the tinnitus help seekers and the other groups. The TH group showed increased scores on all psychological and somatic scales. The TNH group scores were more similar to those of the control subjects than the TH group.
Key Words: Depression • Tinnitus • Somatization
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INTRODUCTION
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This study addresses the question of whether chronic tinnitus patients differ in psychological and somatic profiles from other groups. Chronic tinnitus (constant ringing and buzzing in the ears) is a common complaint among the hearing impaired.1 In population studies, the occurrence of tinnitus varies between 8% and 10%.2 Most individuals habituate to their tinnitus; however, a small percentage do not. According to the epidemiological studies, about 1%–2% of the population is severely disturbed by their tinnitus.2
The question concerning why some individuals adapt to their tinnitus and why some do not touches on the question of different psychological profiles and those factors that can be identified as important in the adaptation process.3,4 To some extent tinnitus characteristics (e.g., the duration and the nature of the perceived sound) have been found to influence the persistence and the maintenance of tinnitus. However, these characteristics do not account for all explained variance. Others have shown that more typical psychological factors, such as depression, anxiety, sleep, and concentration problems, often coexist with tinnitus1,5 and are important markers in predicting whether the tinnitus patient will adapt to the tinnitus.
In a comparative study, Attias et al.6 found more severe psychiatric symptomatology in a help-seeking tinnitus group (TH). This particular group also had a more external locus of control. The non-help-seeking tinnitus group (TNH) had an almost identical profile with the help-seeking group but less severe ratings. However, another comparative study7 does not support these results.
Another question concerns the occurrence of general somatic complaints. Are the individuals suffering from severe tinnitus more susceptible to other somatic or psychosomatic problems? Some evidence supports this hypothesis; Hiller et al.8 found a higher prevalence of tinnitus among primary care patients who met the DSM-IV criteria of somatoform disorder.
To what extent minor daily stressors corroborate with the maintenance of tinnitus is not fully understood. Minor daily stressors or agonies have been found to be positively correlated with reports of several kinds of disorders, like fibromyalgia, irritable bowel syndrome, and chronic pain.9 To our knowledge, no studies have yet shown whether the tinnitus individual per se is more susceptible to daily stressors or hassles than others with chronic disorders.
The present study examines whether the help-seeking tinnitus patients differ in psychological (state-trait) profile from the non-help-seeking tinnitus subjects and control subjects. Important facets of personality such as anger, anxiety, depression and dispositional style are examined. The study also examines if help-seeking tinnitus patients differ in frequency and severity of somatization as well as their susceptibility to minor stressful life events or so-called daily hassles. The manners in which all subjects usually react to stress are also measured. Because of earlier findings,1,4,6 we hypothesize that the chronic tinnitus subject develops a more disadvantageous psychological and somatic profile in comparison with other groups. For our control subjects, we used two samples from a nationwide population sample.10 The first control group comprised subjects with tinnitus but who had not sought help for their tinnitus, and the second control group comprised subjects with no record of tinnitus.
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METHOD
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Procedure
Accompanied by an explanatory letter, a questionnaire containing demographic questions and questions concerning tinnitus and somatic complaints along with self-report scales was distributed by mail to a randomly selected population sample. The primary aim of the questionnaire was to gather information about psychological, somatic, and life-style factors from a health/psychological point of view. Data about negative affect, daily hassles, and attributional style were summarized to get standardized data for these parameters10 as well as the negative mood component in reaction to stress.19 Finally, lifestyle factors, psychosomatic complaints, and the occurrence of tinnitus, hearing impairment, and vertigo were examined.
The sample consisted of 2,500 Swedish residents from the population register. Of those 2,500, 1,538 subjects (62%) completed the questionnaires. Among these 1,538 subjects, 243 subjects (15.8%) reported tinnitus in correspondence with the standard definition criteria2 (continuous tinnitus for more than 5 minutes).
We mailed out an identical questionnaire package to a clinical sample who had sought help at an audiological clinic in Uppsala, Sweden (for details, see below). These consecutive subjects recruited from the clinic had all been examined by a physician. After 3 weeks, we sent out a reminder to all the subjects who had not responded the first time.
Assessment
Tinnitus Incidence and Demographic Questions
To exclude subjects with intermittent tinnitus, the following question concerning tinnitus was formulated: "Have you heard buzzing, roaring or tones, or other sounds which seems to come from inside the ears or the head and that have persisted for 5 minutes or longer? (so-called tinnitus.)" In using this question we expected to exclude subjects who were not bothered by tinnitus. The time limit has been used in a large number of studies to distinguish subjects with persisting tinnitus, and the time limit could be regarded as a standard time frame in tinnitus research. The subjects were also asked to classify their tinnitus into three grades.1 The grades were the following: 1) audible only in silent environment, 2) audible at low environmental noise levels, and 3) audible in all environmental noise levels. We also asked if subjects had sought help specifically for tinnitus, if they had received any treatment, and if so, what kind of treatment they had received. Data concerning socioeconomic index (SEI),11 marital status, residential location, and tinnitus duration were also gathered.
Somatic Complaint Scale
Subjects were asked to report problems of various kinds in all 12 different somatic complaint scales. These somatic complaints included the following: tension-type headache, gastrointestinal difficulties, migraine, sleep, trouble with concentrating, low-back pain (LBP), neck/shoulder pain, muscle tension, high blood pressure, allergy, asthma, and vascular spasms. The response categories ranged from "never" (1) to "always" (5).
Psychological Scales
The Life Orientation Test (LOT) is defined as the subject’s generalized outcome expectancies or dispositional style. The LOT has been shown to be a psychometrically stable scale with high predictive value.12,13 This trait scale contains 12 statements with 4 filler items, and the maximum score is 32. The statements are both negatively and positively phrased. Before scoring, the 4 negatively phrased items are reversed. High values indicate a person with strong beliefs or expectancies regarding his or her own capacity. The response categories range from "strongly disagree"(0) to "strongly agree"(4). Reliability scores of 0.76 (Cronbach’s alpha) have been shown in both American and Swedish populations.10,14
Negative affect was assessed with the Trait Anger Scale (STAS-T)17 containing 15 statements. The maximum score is 60. Response categories range from "almost never" (1) to "almost always" (4). The reliability scores found are high: 0.83,15 0.88,10 and 0.98, respectively.
One of the most frequently used self-report inventories for establishing the severity of anxiety is the State-Trait Anxiety Inventory (STAI).16 The anxiety scale, which has high internal consistency (both scales  =0.90), consists of 2 subscales measuring anxiety as a state, and as a trait.18 The State Anxiety Scale (STAI-S), which was used in the present study, consists of 20 statements, both positively and negatively phrased. After reversing the 10 positive items, the maximum score is 80. The response categories range from "not at all" (1) to "very much" (4). Reliability measures (Cronbach’s alpha) for the STAI-S were 0.8315 and for the Swedish population 0.91.10
Two scales were used to measure reaction to stress. The subject's responses to stress as a trait were measured with the Negative Mood Scale (NM).19 The NM scale is a 19-item adjective checklist. The response categories in this scale are "never" (1) to "always" (5) and the maximum score is 95. The internal consistency of the scale is high (=0.91). The second measure, the Daily Hassles Scale (DH), captures the amount of irritation of perceived stress from daily-life events.20 We used a shortened version with 94 statements. In this version, items removed from the scale contain topics not fully applicable to a Swedish population (e.g., "Neighborhood deterioration" and "Financing children's education"). This scale measures the frequency (DH-F), the cumulative sum of severity (DH-CF), and the intensity (DH-I). The maximum frequency score for DH-F is 94. The cumulative severity (maximum=282) is the sum based on the response categories: "somewhat severe" (1) to "extremely severe" (3). Finally, the intensity measure (range=1–3) is composed of the cumulated sum of severity divided by the frequency. In the present study, analyses of all three measures (DH-CS, DH-F, and DH-I) are presented.
The Epidemiological Studies Depression Scale (CES-D), developed by Radloff,21 includes topics such as feelings of helplessness, hopelessness, guilt, and loss of appetite. The CES-D contains 20 statements phrased in both positive and negative directions. The maximum obtainable score is 60. The response categories for the scale range from "rarely or none of the time" (0) to "most or all of the time" (4). This scale has proved to be stable with a high degree of reliability. In several different samples Cronbach's alpha of 0.80 or higher has been reported.10,21
The Samples
We studied three samples. The first sample, including TNH, was generated from the 243 tinnitus subjects found in the nationwide population survey. Forty-two subjects were excluded. The major exclusion criteria was insufficient answers on the questionnaires (n=33), and a minor proportion of subjects were excluded as they had sought help at an audiological clinic (n=7) for their tinnitus. The treatments reported by the subjects were medical (n=3) and psychological (n=2). Two subjects did not indicate the kind of treatment they had received. Finally, two subjects were excluded because they only had tinnitus for less than 6 months. Thus, the TNH group comprised 201 (13.1% of the population) subjects. The remaining subjects also reported tinnitus according to the criteria set by Coles et al,2 and most of the subjects had their tinnitus for a long time (Table 1). The TNH group consisted of 56.7% men (mean=52.6 years, range=19–82 years) and 43.3% women (mean=52.1 years, range=18–83 years).
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TABLE 1. Demographic variables, tinnitus duration, grades of tinnitus and hearing impairment for the tinnitus help-seeking group (TH), the tinnitus non-help-seeking group (TNH), and the control subjects (C) (N=634
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The tinnitus help-seeking group (TH) consisted of subjects all suffering from chronic tinnitus. A total of 168 patients were asked to fill out the questionnaires, and 117 patients (69%) agreed to do so. As for the duration of tinnitus, almost two-thirds (61%) had tinnitus for more than 5 years. One had tinnitus for less than 6 months; we excluded that single subject from the study. All subjects had sought audiological expertise for their problem, and the majority had received some kind of treatment. About half had received medical treatment (47%); 23% reported that they had tried individual or group psychological treatment. Sixteen percent had tried some type of technical aid, 11% had tried acupuncture, and, finally, 3% reported that they had tried physiotherapy. The TH sample comprised 54.3% men (mean=53.9 years, range=22–78 years) and 45.7% women (mean=55.7 years, range=20–77 years).
In the TH sample, no significant gender, duration, or age differences were found between the subjects who chose to participate and those who did not.
Age and gender were checked for differences between the TH and TNH—groups. No significant differences could be found (gender,  2=0.36; age t=-1.23). The grades of tinnitus differed significantly (Table 1).
The comparison group (C), that is, subjects without problems with tinnitus, was recruited from the population sample, and the subjects were explicitly chosen to match the other two sample groups in gender and age. Thus, this group consisted of 317 subjects (men, mean=58.3 years, range 19–82 years: women, mean=54.2 years, range 18–83 years).
Statistical Procedures
Analysis of covariance (ANCOVA), test for homogeneity (Cronbach’s Alpha), t-test, and Chi-square test were used. Because of the unequal sample size, the Spjotvoll-Stoline corrections of honestly significant differences were used in post hoc test in the analysis of covariance.22
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RESULTS
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The reliability for the psychological measures used was generally high (Cronbach's alpha 0.70–0.96). The comparisons between the three groups and the psychological scales are presented in Table 2 (means, standard deviation, and F-values).
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TABLE 2. Means, standard deviations, and F-values for the psychological scales for the tinnitus help-seeking group (TH), the tinnitus non-help-seeking group (TNH), and the control subjects (C) (N=634
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The TH group deviates from the two other groups by showing increased scores on all measures, indicating more problems for this particular group. The effect sizes varied from 2% (LOT, DH-F) to 9% (STAI-S). It is worth noting that the TH group showed lower values on dispositional style (LOT) (i.e., this group had lower expectancies regarding outcome than the other groups). Post hoc test showed significant differences among all three samples for CES-D and STAI-S (P<0.001). Noticeably, the TH group met the criteria for depression in the CES-D, which is set at a score of 16.21 For LOT, NM, DH-CS, and DH-I, significant differences were found between the TH and the C group (P<0.001). Significant differences were also found between the TNH and the C group for the variables DH-CS and DH-F (P<0.01).
In all, 12 somatic complaint variables were analyzed with ANCOVA. Problems with asthma, allergy, hypertension, gastrointestinal problems, vascular spasms, and migraine did not show any significant differences between groups and are therefore excluded from the presentation in Table 3.
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TABLE 3. The somatic complaints for the tinnitus help-seeking group (TH), the tinnitus non-help-seeking group (TNH), and the control subjects (C) (N=634
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The TH group showed the highest mean scores on all variables except LBP. As expected from earlier findings,1 the TH group had markedly more problems with sleep, concentration, and muscle tension. Post hoc tests showed significant differences between all groups for problems with sleep and concentration. For headache and muscle tension, significant differences were found between the TNH and the C groups and the TH and the C groups, respectively. The effect sizes varied between 2% (headache) to 14% (sleep).
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DISCUSSION
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The TH group differed both on the trait (NM, LOT, STAS-T) and state scales (STAI-S, CES-D, DH) from the two other groups. Elevated scores were found for anxiety (STAI-S), depression (CES-D), and reactions to stress (NM) when hearing impairment was controlled. Thus, the findings are not an effect of differences in hearing impairment. The TH group also reported having more somatic complaints, especially problems with sleep and concentration compared with the TNH group and the control subjects. Although the effect sizes are rather small, this finding is in accordance with earlier findings.1,8 One should also keep in mind that the effect sizes rely on the sample size and with the large sample sizes in this study, it is less plausible to achieve high effect sizes. The grades of tinnitus as well as the tinnitus duration differed between the two tinnitus groups. The duration differed on a low level of significance and the grades markedly more. This is not surprising in view of sample selection. Subjects seeking help ought to be more burdened with their tinnitus. As these variables do not occur in the comparison group, they were not used in the analysis as covariates. The psychological measures used show that both the trait and the state measures distinguish the groups. The TH group also shows a pattern of increased vulnerability. Although the differences are small, they are of clinical interest. A clinician would usually meet with subjects who report a multifactoral pattern of complaints, and it would, thereby, be easier to draw the conclusion that these tinnitus subjects are representative of the patient group as a whole.23
When the TNH group, recruited from the population, with less profound tinnitus was compared with normal control subjects, no significant differences in the psychological profile were found except for two: the severity and the frequency of daily hassles. As for somatic complaints, the TNH group had more problems with LBP compared with control subjects and the TH group. Further, the TNH group suffered significantly more headaches and muscle tension compared with control subjects. Similar significant differences were also found for sleep and concentration. The TNH group does not particularly differ from the TH group on headache and muscle tension, although it does in sleep and concentration (Table 3). Although significantly different from both groups, the TNH group is closer to the control group on these two latter complaints. Problems with sleep and concentration have been shown to be negative markers for the natural adaptation process.1,5 These earlier findings are thus supported in this study. We argue, therefore, that the TNH group is representative of tinnitus-inflicted persons who have naturally adapted to their problem and are in no need of audiological expertise, although the situation of the TH group is the opposite. These findings are further supported by the fact that the TNH group consists of 13.1% of the population, and that this sample proportion is representative and similar in size compared with other findings.24,25 Thus, this study confirms our hypothesis that the chronic tinnitus patient is different in psychological and somatic profile compared to other groups.
In conclusion, this study shows that the TNH group is more similar to the unafflicted comparison group than the TH group. The same situation is true for both the psychologically related problems associated with tinnitus and for the somatic complaints.
For the chronic help-seeking tinnitus patient, the links between anxiety, depression, reactions to stress, and tinnitus are confirmed. This particular group is also more burdened with more severe somatization problems, which might result in a less adaptive repertoire of coping strategies. The results also show a pattern of multifactorial problems for this particular group that emphasizes the importance of a broad spectrum of data collection. This is of particular interest in treatment planning and may help discriminate possible obstacles to treatment outcome.
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S. Zoger, J. Svedlund, and K.-M. Holgers
Relationship Between Tinnitus Severity and Psychiatric Disorders
Psychosomatics,
August 1, 2006;
47(4):
282 - 288.
[Abstract]
[Full Text]
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ABSTRACT
INTRODUCTION
