Introduction

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

Materials and Methods

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

Data assessment

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

Statistical methods

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

Results

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

Table 1: Clinical characteristics of the patients with tinnitus.

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

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

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

Discussion

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

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

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

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

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

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

Conclusion

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

Conflict of Interest

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