Table 1: Average, standard deviation, and range of the scores on the TCQ, THI, and HADS.

Validity-reliability analysis: For the assessment of internal consistency reliability, Cronbach’s alpha was 0.933 for the total score on the TCQ, 0.974 for the negative subscale, and 0.950 for the positive subscale. test reliability was assessed as a second investigation in 75 patients. The ICCs for the total score and two subscales are shown in Table 2. The ICC of the total score was rather high (0.963) and the ICCs of the negative and positive subscales were lower than that of the total score (0.631 and 0.679, respectively).For the assessment of structural validity, the optimal number of factors was two. We assessed the factor pattern and factor structure matrix using Promax rotation (Table 3). One of two factors corresponded exactly to the negative subscale, whereas the other one corresponded to the positive subscale.

Table 2: Intraclass correlation coefficients for test−retest reliability.

Table 3: Factor matrix, commonality, and interfactor correlation in the factor analysis.

Relationship between cognition and other psychometric properties in patients with tinnitus

Pearson’s correlation coefficient was used to assess the convergent/discriminant validity, as shown in Table 4. There was a weak correlation between the negative and positive subscales of the TCQ. The negative subscale score of the TCQ was strongly correlated with the total score and the scores on the three subscales of the THI (0.438?0.656), whereas moderate correlations were detected between the scores on the depression and anxiety subscales of the HADS (0.416 and 0.450, respectively). Conversely, the positive-subscale score of the TCQ was weakly correlated with the total score and the scores on the three subscales of THI and on the depression and anxiety subscales of the HADS (0.009?0.162).

Table 4: Construct validity: Pearson’s correlation coefficients between variables.

Discussion

The TCQ contributes to knowledge about the type and frequency of thoughts in relation to tinnitus. The English version of the TCQ was previously validated in 200 individuals from Australia and 342 individuals from the United Kingdom [15,16]. The findings of the present study provided support for the use of the TCQ in tinnitus research and in clinical practice in Japan, in a setting with different languages and cultures. The Japanese version of the TCQ also exhibited a two-factor structure, and negative cognition for tinnitus was greatly related to handicap and psychological state, whereas positive cognition for tinnitus was an independent thought process.Tinnitus is an auditory sensation that can cause discomfort or even pain; moreover, patients with tinnitus generally live with their problem for long periods [17]. Some patients with severe chronic tinnitus need cognitive behavioral therapy. When performing cognitive behavioral therapy, it is necessary to evaluate the patient’s cognition for tinnitus and the changes in cognition after treatment. The TCQ is useful to assess the patient’s cognition regarding tinnitus. The Japanese version of the TCQ proved to be a credible tool for the evaluation of tinnitus cognitions. The internal consistency ratio was sufficiently high. In the test?retest, the total score was sufficiently high; however, the scores on the positive and negative subscales were lower than the total scores of the TCQ. The Japanese version of the TCQ also exhibited a two-factor structure, and there was no correlation between the negative and positive subscales; therefore, changes in the negative and positive subscales were considered to occur independently. Handscomb et al. reported that negative thinking appeared to be associated with more problematic tinnitus [16]. This study also showed that patients with a severe handicap for tinnitus had more negative cognition. Considering these facts, to reduce the handicap for tinnitus, it is important to educate and counsel patients to decrease their negative thoughts for tinnitus. A previous study stated that positive thinking was not associated with unproblematic tinnitus, and the highest mean score on the positive subscale (indicating fewer frequent positive thoughts) was obtained for patients with no problem for tinnitus. This study also showed that positive cognition was weakly correlated with handicap for tinnitus, whereas there was no relationship between low frequency of positive thoughts and no handicap for tinnitus. Over time, and after improvement to the no-handicap condition, patients may have less frequent thought of both negative and positive nature. Therefore, the changes in cognition for tinnitus in the TCQ after treatment should be clarified in the future. Regarding the relationship between cognition for tinnitus and psychological state, Wilson et al. reported that depression evaluated by the Beck Depression Inventory was strongly correlated with the negative subscale and weakly correlated with the positive subscale. In this study, similar results were obtained for depression. Patients with many negative thoughts needed to be aware of their depression. Conversely, the relationship between TCQ scores and anxiety has not been reported. In this study, anxiety also exhibited a strong correlation with the negative subscale and a weak correlation with the positive subscale. The positive subscale of the TCQ was suggested to be an evaluation point that is independent of tinnitus handicap and psychological state. The discriminatory validity and convergent validity with respect to the TCQ and the THI and HADS have been demonstrated. This study had several limitations. The first limitation concerns the interval between the first test and the retest; the risk of recall bias cannot be ruled out because of this short interval. In the setting of this study, retest was set to 3?7 days after the first session, because the state of tinnitus in these patients changed easily and was considered to be the limitation of this test. Validation of the TCQ examination in a non-hospital environment or in the general population is an important next step of this research. Second, the present study was conducted among a population in a secondary and tertiary care context in Japan using the Japanese version of the TCQ. Therefore, further research is required in other languages and other populations. Finally, we did not evaluate the changes in the TCQ over time, or the responsiveness or interpretability of the TCQ in this study. Additional studies are required to examine these aspects.

Conclusion

The first validation of the TCQ in a language other than English for the evaluation of tinnitus cognitions was reported here. The Japanese version of the TCQ also exhibited a two-factor structure that was well matched with previous data; moreover, the Japanese version of the TCQ was a highly consistent and reliable measure that can be used to evaluate cognitions in patients with chronic tinnitus. Negative cognition for tinnitus was strongly correlated with handicap and psychological state, whereas positive cognition for tinnitus was an independent thought process.

Conflict of Interest

The authors declares no conflict of interest

Acknowledgment

The authors would like to thank Enago (www.enago.jp) for the English language review

Statement of Ethics

This study was approved by the Research Ethics Committee, Graduate School of Medicine, at Nagoya City University (60-17-0065) and was conducted according to the tenets of the Declaration of Helsinki. A written informed consent was made by signing the questionnaire.

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