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Psychosomatics 47:282-288, August 2006
doi: 10.1176/appi.psy.47.4.282
© 2006 Academy of Psychosomatic Medicine
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Relationship Between Tinnitus Severity and Psychiatric Disorders

Sigyn Zöger, M.D., Jan Svedlund, M.D., Ph.D., and Kajsa-Mia Holgers, M.D., Ph.D.

Received January 19, 2005; revised June 27, 2005; accepted August 9, 2005. From the Institute of Clinical Neuroscience, Psychiatry Section, and the Dept. of Audiology, Sahlgrenska Univ. Hospital, Göteborg Univ., Göteborg, Sweden. Send correspondence and reprint requests to Jan Svedlund, M.D., Ph.D., Dept. of Psychiatry, Sahlgrenska Univ. Hospital, SE-413 45 Gothenburg, Sweden. e-mail: jan.svedlund{at}neuro.gu.se


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A close association between tinnitus and psychiatric disorders has been demonstrated, but little is known about how the severity of tinnitus is related to these disorders. The authors investigated the strength of the association between tinnitus and both the prevalence and severity of anxiety and depressive disorders. One study group consisted of 80 consecutive patients and another of 144 patients who were deemed by screening to be at high risk for severe and disabling tinnitus. The severity of tinnitus was assessed by clinical gradings on a 3-point scale and by the Tinnitus Severity Questionnaire. DSM-III-R criteria were used to identify psychiatric disorders by structured clinical interview. The Hospital Anxiety and Depression Scale (HADS) and the Comprehensive Psychopathological Rating Scale (CPRS-S-A) were used to assess the severity of anxiety and depression. There was a correlation between the severity of tinnitus and depression in both study groups; however, the corresponding correlations for anxiety disorders were lower, and reached statistical significance only in the high-risk group. Various measures found significant correlations between the severity of tinnitus and the severity of depression and anxiety. We conclude that the severity of tinnitus is associated with psychiatric disorders, as well as with the severity of anxiety and depression in tinnitus patients, and may account for approximately 20% of the variance of the observed association.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Subjective or idiopathic tinnitus is a common symptom that is reported to occur in approximately 10%–14% of the general population. In 1%–2%, it is severe enough to cause significant discomfort in daily life.1,2 Tinnitus is often related to hearing loss, but not all tinnitus patients have a measurable hearing impairment.1–5 The perceived severity of tinnitus correlates closer to psychological and general health factors, such as pain or insomnia, than to audiometrical parameters.4,6–15 Patients with the most severe tinnitus also report a higher burden of psychosocial stressors than those with less severe difficulty.16

Tinnitus symptoms have been linked to various psychological and psychosomatic problems,7,8,17–26 and a high prevalence of comorbid depressive disorders has been reported in patients seeking help for tinnitus.18,27–34 The occurrence of major depressive disorder (MDD) in patients with chronic or disabling tinnitus has been found to be between 48% and 60%,31,32 and, in a study of tinnitus patients with pure-tone hearing thresholds better than 50 dBHL, we found current depressive disorders among 39% and current anxiety disorders among 45%.28 Furthermore, in a study of patients at high risk for developing severe tinnitus, two-thirds of the patients had current depressive disorders.29 An emerging body of data concerning efficacy of psychopharmaceuticals in tinnitus treatment supports the benefits of antidepressants for tinnitus,30,35–38 indicating an interaction between suffering from tinnitus and having psychiatric disorders. Despite these findings showing a close association between tinnitus and psychiatric disorders, our understanding of how the severity of tinnitus relates to these disorders is still limited. The aim of this study was therefore to investigate the relationship between the severity of tinnitus and comorbid depressive and/or anxiety disorders.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Patients and Study Design
Two study groups were recruited from three series of patients referred to an audiological physician at the Department of Audiology, Sahlgrenska University Hospital with tinnitus as their major complaint. One study group consisted of 80 consecutive patients, and the second consisted of 144 patients recruited from two series of patients considered to be at high risk of developing chronic and disabling tinnitus. Initially, audiometry, including pure-tone hearing thresholds and speech recognition tests, was performed. Only patients with PTA 0.5, 1, 2 kHz or PTA 3, 4, 6 kHz ≤50 dBHL were included. The PTA criteria were used to avoid psychological biases from social isolation caused by hearing loss. The Swedish version of the Nottingham Health Profile (NHP)39 was used in the screening procedure to identify patients between 18 and 65 years old at high risk for severe and disabling tinnitus. This method has been described in detail elsewhere.16,22 Patients in the High-Risk group who were on sick leave, retired, had language difficulties, or receiving psychiatric treatment were excluded. The 80 Consecutive patients were invited for a psychiatric evaluation at 24 months after their first consultation at the audiology clinic. The 144 patients from the High-Risk group were invited for psychiatric evaluation immediately after their first visit to the clinic.

A standardized diagnostic interview (the Structured Clinical Interview for DSM-III-R, Patient Edition [SCID–P])40 for multiaxial psychiatric diagnosis (DSM-III-R, Axis I–V), in accordance with the Diagnostic and Statistical Manual of Mental Disorders system,41 was used for both study groups. The interview was conducted by an experienced psychiatrist trained in the SCID procedure. Immediately after the psychiatric interview, the Hospital Anxiety and Depression Scale (HADS)42 was administered to both study groups. Also, the Comprehensive Psychopathological Rating Scale (CPRS-S-A) subscales for depression, anxiety, and obsessive-compulsive disorder, for self-rating,43–46 was given to the High-Risk group. To control for potential administrator bias, the patients completed the HADS and the CPRS-S-A in a separate room monitored by a second research assistant. The study was approved by the ethics committee at Sahlgrenska University Hospital.

Subjects
Study Group 1 (Consecutive Tinnitus Patients)
Of 172 consecutive patients, 98 with pure-tone averages better than 50 dB HL in the worse-hearing ear were eligible for the study. Sixteen patients were not willing to take part, and there were two dropouts because of inconclusive answers about perceived tinnitus severity. The remaining 80 patients comprised the study group. There were 50 men and 30 women; the median age was 50 years (inter-quartile range: 36–56 years), and the median duration from onset of tinnitus was 45 months (inter-quartile range: 30–71 months).

Study Group 2 (High-Risk Tinnitus Patients)
Of 239 consecutively referred patients, 29 were excluded because of age or retirement criteria. Of the 72 patients who met the screening criteria, all but 4 fulfilled the criterion of having pure-tone averages better than 50 dB HL in the worse-hearing ear. The remaining 68 patients were recruited for the present study. From another series of 753 consecutively referred patients, 460 fulfilled the screening criteria. Of these, 362 had pure-tone averages better than 50 dB HL in the worse-hearing ear; 210 patients were excluded for the following reasons: age (N=40); sick leave or retirement because of illness (N=94); language difficulties, including dyslexia (N=3); and current psychiatric contact (N=73). Seventy-six patients were not willing to take part in the study. The remaining 76 patients were recruited for the present study.

In all, Study Group 2 consisted of 144 patients at high risk of developing chronic and disabling tinnitus. There were 86 men and 58 women; the median age was 48 years (inter-quartile range: 35–56 years); and the median duration from onset of tinnitus was 24 months (inter-quartile range: 12–60 months).

Measures
Tinnitus severity assessments
In the consecutive tinnitus group (N=80), the severity of tinnitus was rated according to an interview-based, single-item measure developed for this study. This measure was designed to evaluate the current severity of tinnitus in three categories: 1) no or transient tinnitus; 2) intermittent tinnitus only in specific situations; and 3) continuous and/or severe tinnitus.

In the High-Risk group (N=144), the severity of tinnitus was measured by the Tinnitus Severity Questionnaire (TSQ).3,6,7,22,47 The TSQ includes 10 items, each yielding a score from 0 to 4 on the dimension "not affected" to "always affected." The TSQ scores range between 0 and 40, a high score implying more discomfort from tinnitus.

Psychiatric assessments: Structured Clinical Interview for DSM
Since the most frequent diagnostic categories among tinnitus patients are anxiety disorders and mood disorders, the term "psychiatric disorder" in the present study will refer to anxiety, depressive, or mixed disorders. We used the SCIP–P for multiaxial psychiatric diagnosis in accordance with the DSM-III-R to record the following diagnostic groups: current minor depression, current major depression, one current anxiety disorder, multiple current anxiety disorders, and any current depressive and/or anxiety disorder.

Hospital Anxiety and Depression Scale (HADS)
The HADS is a 14-item, self-rating instrument with subscales for depressive disorders (seven items) and anxiety disorders (seven items). Each item uses a Likert scale (0–3), and each subscale accordingly ranges from 0 to 21. In general medical practice, the suggested cut-off score to screen for possible cases of depressive or anxiety disorders is ≥8, and for probable cases of anxiety and depression, ≥11.42 The HADS was developed for use with medical outpatients, rather than psychiatric patients. Symptoms that are as likely to arise from somatic as from mental disorders are excluded from the scale, which means that the scale scores are not affected by physical illness. Scores are calculated for each subscale and for an overall score.

Comprehensive Psychopathological Rating Scale (CPRS-S-A)
We used a self-rating scale (CPRS-S-A) based on 19 items from the original CPRS, with subscales for depression, anxiety, and obsessive-compulsive syndromes.43–46 Each item uses a Likert scale (0–6). The CPRS-S-A was developed to be a clinically handy, useful, and reliable instrument for the quantitative rating of depression, anxiety, and obsessive-compulsive symptoms in psychiatric outpatients. The CPRS data are presented in subscale scores for depression and anxiety, along with a total score.

Statistical Analysis
Pearson's product-moment correlation coefficients were used for descriptive purposes to estimate the strength of association between the two measures of the severity of tinnitus and the psychiatric assessments. The significance of the correlations were tested with Pitman's nonparametric permutation test.48 In all, 19 variables were tested (Table 1). To describe possible Type 1 errors, the upper limit of expected number of false significances was calculated according to the following standard formula: {alpha} (N – n ({alpha})/(1–{alpha}), where N=number of tests, n ({alpha})=number of significances on the –{alpha} level, and {alpha}=significance level. In our study, the upper level of false significances was thus estimated to 0.02. To indicate the clinical relevance of the magnitude of the correlations, the mean scores for measures of tinnitus severity were calculated for the different diagnostic groups and compared with the mean scores for patients with no current psychiatric disorder. These mean differences were then divided by the pooled standard deviation (SD) for each pair of comparisons, to acknowledge the large (>0.80), moderate (0.50 to <0.80), and small (0.20 to <0.50) effect sizes (ES).49 All significance tests were two-tailed and conducted at the 1% significance level to allow for Type 1 errors.


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TABLE 1. Correlations Between Tinnitus Severity and Prevalence of Depression and Anxiety Disorders (SCID) and Ratings of Depression and Anxiety Severity (HADS and CPRS)




  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
In Group 1 (the Consecutive Tinnitus Patient group), according to the SCID interview, 39% had a current minor depression; 33%, a current major depression; 45%, any current anxiety disorder; 13%, multiple anxiety disorders; 46%, any current Axis I disorder; and 54%, no current Axis I disorder. The corresponding figures for Group 2 (the High-Risk Tinnitus Patient group) were: 74%, minor depression; 52%, major depression; 49%, any current anxiety disorder; 19%, multiple anxiety disorders; 81%, any current Axis I disorder; and 19%, no current Axis I disorder.

As shown in Table 1, the correlations between severity of tinnitus and depression were highly significant in both study groups. The corresponding correlations for anxiety disorders were lower, and reached statistical significance in the High-Risk group only. However, correlations between the severity of tinnitus and the severity of depression, as well as anxiety according to the HADS, were significant in both study groups, and the results of the CPRS followed the same pattern in the High-Risk group. The mean scores for the severity of tinnitus in the different diagnostic subgroups and among patients with no current psychiatric disorder are shown in Table 2. The effect sizes were moderate and similar for the different diagnostic groups in the High-Risk group, but small in the Consecutive group, especially for anxiety disorders.


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TABLE 2. Mean Scores for Tinnitus Severity According to Clinical Grading in the Consecutive Group and the TSQ in the High-Risk Group, by Diagnostic Subgroup (SCID)




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
In the present study, we have shown that the severity of tinnitus in these patients is associated with psychiatric disorders as well as with the severity of anxiety and depression. Interpretation of the clinical relevance of this finding is problematic because causation cannot be directly inferred. Severe tinnitus certainly has an impact on a patient's daily life and may, like other health problems, secondarily result in anxiety and depression. On the other hand, patients with mood disorders commonly tend to overestimate the importance of psychosocial stressors, which may result in tinnitus being perceived as more severe by depressed patients. Still another possible explanation may be a common biological or pathophysiological mechanism, as proposed by the neurobiological vulnerability model.50

Tinnitus sufferers may have a particular vulnerability to the stress impact of the tinnitus sound, as such. A genetic cause of such vulnerability to stress could hypothetically be a shared neurobiological pathway for developing both depression and tinnitus. The influence of life stress on depression has recently been shown to be moderated by a polymorphism in the 5-HTT gene.51 An acquired vulnerability in the form of a sensitization of the HPA axis has been discussed for anxiety disorder52,53 as well as for depressive disorders.54 It may be that patients with depressive and anxiety disorders, where stress effects have already caused neurobiological changes,55 and neurochemical dysfunctions in the brain56–58 could easily be prone to extreme suffering from an otherwise benign tinnitus sound.

Comorbid depressive disorder, however, is probably the most important factor behind chronic disability and suffering in tinnitus patients, as well as in patients with chronic pain.30,59 The close association between depressive disorders and tinnitus is similar to the relationship between chronic pain and depression.59–62 Also, our data suggest that comorbid depressive disorders may worsen the prognosis for tinnitus disability.30,63The High-Risk group, selected for poor prognosis, showed a significantly higher prevalence of current depressive disorders (74%) than the Consecutive group (39%).

The high percentages of current anxiety disorders in both study groups, almost 50%, are to be expected in patients who have such a high prevalence of depressive disorders. In the United States National Comorbidity Survey, 58% of patients with MDD also met criteria for an anxiety disorder.64 It has been documented that most patients with primary anxiety disorders also develop major depressive episodes and that 68% of patients with comorbid depression and anxiety had been anxious for over 10 years before the development of depression.64,65 The overlapping symptoms between the diagnostic entities of depressive and anxiety disorders have been discussed for more than 10 years, and a shared pathophysiology has been suggested.66–68

Our results appear to be reliable; they are supported by similar findings in two different study groups who were examined with different measures of tinnitus severity and at different times in the course of the disorder. One study group was a consecutively-recruited group, whereas the other was systematically selected from consecutive tinnitus help-seekers to single out those who have the poorest prognosis for recovery from tinnitus. The high-risk patients were evaluated immediately after their first visit to the audiology department, whereas the consecutive patients were studied at a 24-month follow-up.

We used two recognized self-report questionnaires for assessment of the severity of anxiety and depression. The HADS was chosen because it was developed for use with medical outpatients and has been reported to be an effective screening tool for possible anxiety or depressive disorders in medical settings. The CPRS was chosen to supplement the HADS because it has been shown to be a reliable and valid instrument for the quantitative rating of depressive and anxiety symptoms in psychiatric outpatients. We continued to use the SCID in accordance with DSM-III-R because the interview schedule based on DSM-IV criteria was not available in 1997, when our data collection was started. The Swedish version of SCID: DSM-IV was published in 1998. However, given the broad categories (any anxiety or depressive disorder) used in our study and the unchanged diagnostic criteria for major depression in DSM-IV, we feel fairly certain that the results would have been the same if we had used the current DSM-IV criteria. Different methods for the assessment of tinnitus have been suggested, but there is no consensus in the grading of its severity. The assessment of tinnitus severity in the present study was performed with the TSQ, which has been reported to have good test–retest reliability and high internal consistency.6,7,47

In our study, the strength of the association between tinnitus and psychiatric diagnoses was moderate-to-low, which means that factors other than tinnitus severity account for most of the variability. The impact of tinnitus severity was also moderate-to-low according to the effect-size calculations. One way of looking at the data is to calculate R2, which is the percentage of the variability of the data that is explained by the association between the examined variables. Given the correlations in our study, approximately 20% of the variability may be accounted for by the observed association.


  CONCLUSIONS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The severity of tinnitus is associated with psychiatric disorders as well as with the severity of anxiety and depression in tinnitus patients. The study results elucidate the clinical significance of the severity of tinnitus and indicate that it is important to take depression and anxiety disorders into account in the treatment of tinnitus patients. Future research is needed to study the influence of psychiatric diagnoses and psychological factors as they affect symptom expression and outcome in tinnitus patients and also to determine the benefits of psychotherapy and psychotropic drugs


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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BMJ, August 26, 2006; 333(7565): 454 - 454.
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