Jownol ,<fP~vrhosomnr,c Resrorch. Vol. 35, No 415. pp 383-390, Prmted in Great Britam.

1991 0

0540-3999/91 53.00+ 00 1991 Pergamon Press plc

ANXIETY

AND DEPRESSION

IN TINNITUS

SUFFERERS

JONATHAN B. S. HALFORD* and STEWART D. ANDERSON

(Received 16 October 1990; accepted in revised

form 24

January

1991)

Abstract-This paper focuses upon the relationship between tinnitus and personality. One hundred and twelve members of a tinnitus self-help group completed psychological and tinnitus questionnaires. In line with prior studies we found that tinnitus was associated with elevated anxiety trait and depression. Unlike previous work, use of a validated subjective tinnitus scale allowed us to directly test the strength of association. Although both anxiety trait and depressive tendency were significantly correlated with overall tinnitus severity, the coefficients were of low magnitude. Advancing age was related to a reduction in depressive tendency; and being male was associated with lower anxiety and depression scores. While hypothesizing a bi-directional causality between personality and the impact of tinnitus, we acknowledge that only longitudinal research can unequivocally test this.

INTRODUCTION TINNITUS, is the experience of hearing sound from the ears or head where no external sound source is present. It does not fit a single disease structure model, but is a disorder of multiple causality [ 11. Noise exposure is a common cause, but many ear disorders can lead to tinnitus. The prevalence of sustained tinnitus, of a form likely to lead to medical consultation is estimated at 2-7 % of the adult population [2-41. Generally, tinnitus reflects no serious underlying pathology. Also in the vast majority of cases the sound level can not be objectively measured: however, it can be estimated by matching the intensity of the tinnitus to a noise produced by an audiometer. Using this technique the sensation level of the tinnitus is usually only slightly above threshold and bears little relation to the degree of subjective complaint [51. However, tinnitus can potentially cause psychological distress out of proportion to its relatively small sensation level. This potentially distressing aspect of tinnitus, Vernon has likened to Chinese water torture [61. Using the Crown-Crisp Experiential Inventory, Stephens and Hallam [71 found anxiety and depression elevated in ENT clinic attenders complaining of tinnitus, when compared with normative values. Whereas another study [81 found no differences in neuroticism (using the Eysenk Personality Inventory), between ENT clinic attenders specifically complaining of tinnitus, and those who acknowledged tinnitus upon questioning, but were referred for other reasons. Presenting graphic and illustrative data, Reich and Johnson [91 indicated that their tinnitus clinic patients showed increased psychopathology on the Minnesota Multiphasic Personality Inventory. A postal survey [lo] of a tinnitus self-help group found that 70% of 72 respondents included emotional problems in their list of common difficulties. Post hoc semantic analysis indicated that one third of respondents complained of tinnitus-related relaxation/irritation/annoyance and/or depression/despair/frustration problems (statistical significance levels not reported).

Department of Neurophysiology, *Author to whom correspondence Hospital, Cromwell Road, London

Cromwell Hospital, should be addressed SW5 OTU, U.K. 383

London. at: Department

of Neurophysiology,

Cromwell

384

J. B. S. HALFORD and S. D. ANDERSON

In the above studies comparisons were made between differences in psychopathology between tinnitus patients and normals (or tinnitus non-complainers). Our approach was different in that we chose a sample of serious tinnitus sufferers (a self-help group), and examined the relationship between the degree of tinnitus severity within this group, in relation to anxiety trait and depressive tendency levels. Kirsch eb al. 1111 bridges both approaches, with comparative groups and direct measures. However these researchers were interested in assessing single, selfperceived tinnitus variables (annoyance, coping and loudness) using a visual analogue technique. In contrast we employed a questionnaire to yield an overall total score, across a variety of tinnitus complaints. This measure (the Subjective Tinnitus Severity Scale [STSSI) is a reliable and clinically valid evaluation of tinnitus severity [ 121. Anxiety trait was measured using the trait section of Spielbergers State-Trait Anxiety Inventory (STAI) 1131. A Depressive Tendency Questionnaire (DTQ) was employed, as this has been shown to be sensitive to sub-clinical depressive tendency 1141. Clinical scales of depression while suitable for psychiatric screening [ 151, can lack sensitivity in estimating depression in general health care settings 116-181 (for DTQ reliability and validity data: see Method). A four-item scale of tinnitus variability (TV) was also employed. Predictions and intentions

In view of the above research, we presumed that increased tinnitus severity would be related to higher anxiety and depression levels. While predicting this relationship, we were also interested in examining the extent to which anxiety trait, depressive tendency and tinnitus severity, directly related. We also wished to determine whether increased tinnitus variability would lead to heightened anxiety and depression. This being based on the premise that greater variability would lead to enhanced attentional focus, and hence poorer adaptation.
METHOD

Subjects Forty-four males, 64 females, and 4 of unstated sex, being 112 members of a local group of the British Tinnitus Association (BTA). The mean age was 61.9 yr (range 29-87 yr, with approximately 70% between 50-75 years old). Most were long-term tinnitus sufferers (82% had suffered for four years or more). Questionnaire Amiety trait. This was measured by the trait component of Spielbergers State-Trait Anxiety Inventory (STAI) form Y. This consists of 20 statements, with a choice of four responses. Tim&us severity. Tinnitus severity was assessed using the 16-item, binary response (yes/no) Subjective Tinnitus Severity Scale (STSS). This is a method of estimating overall tinnitus severity according to how intrusive, prominent and distressing is the tinnitus. The STSS has a separate supplementary scale: Tinnitus Variability (TV), with four binary (yes/no) items; TV being a neutral measure of how much the tinnitus fluctuates. See Appendix for STSS and TV items. Depressive tendency. This was measured using a 35.item binary (yes/no) Depressive Tendency Questionnaire (DTQ). This reflects both depressive history and current state. It has been validated on a psychiatric out-patient sample (N = 3 1); where it correlates with the Hamilton Depression Rating Scale [ 191 (r? = 0.63, p < 0.001) and the American Psychiatric Societys DSM-III-R, depression classification system 1201 (r = 0.58, p<O.OOl). The internal consistency reliability is high (in this tinnitus study coefficient alpha = 0.82). The DTQ comprises two sections. The first entails 28 Inferential Depression Items (IDI) relating to cognitions and behaviour. The second section has six items making up the Professional Contact for

Anxiety,

depression

and tinnitus

385

Depression (PCD) sub-scale; a seventh item relates to a past perceived need for professional help. The items are listed in the Appendix. The full DTQ was administered, but three health-related questions were omitted from analysis to guard against an erroneously high correlation with tinnitus severity (perceived general health, fitness and adequacy of sleep).
Procedure One hundred and fifty questionnaire data sheet were mailed to officials of were then passed on by post to the compliance. Respondents completed research centre. The response rate of

packages containing the STSS, STAI, DTQ and a biographical a local tinnitus self-help group, acting as intermediaries. These regular fee-paying members along with literature encouraging the questionnaires anonymously, mailing them directly to the 112 was high at 75%.

RESULTS

The relationship between Tinnitus Depressive Tendency (DTQ)

Severity

(STSS) Anxiety

Trait (STAI) and

One-tailed t-tests with individuals grouped according to high or low STSS, showed that elevated tinnitus severity was significantly associated with both higher mean anxiety trait (46.3 vs 39.9, p < 0.01) and depressive tendency levels (14.4 vs 7.1 p < 0.001). However, correlation data demonstrates that the degree of direct association between either psychological variable and tinnitus, while significant, was of low magnitude (STSSSTAI 6 = 0.28, one-tailed p<O.Ol; STSWDTQ r* = 0.32, onetailed p < 0.001). Anxiety trait and depressive tendency correlated more highly with each other (9 = 0.76, one-tailed p < 0.001). On two-way analysis of variance, there was no interaction effect between anxiety and depression, with tinnitus severity as the dependent variable. STSS, STAI, and DTQ: age and sex effects pro-

t-Tests examining the potential effects of age and sex on the main variables, duced the results shown in Table I.
TABLE I.-SHOWS THE RESULTS VARIABLES, OF t-TESTS BETWEEN AND AGE, SEX AND THE MAIN

STSS,

STAI Ns

DTQ t-obs 0.26 1.05 2.15 t-obs 0.99 -2.74 -3.06 Probability 2tai1.p = NS Z-tail. p = NS 2-tail.p<0.05 Probability 2-tail. p = NS I-tail.p<O.Ol I-tail.p<O.Ol

Ind.Var. Age Age Age Ind.Var. Sex Sex Sex

Dep.Var. STSS STAI

Older 9.5 42.1 9.9 Male 9.6 39.3 9.1 means:

Younger 9.6 44.9 12.3 Female 9.6 46.2 12.4

DTQ

56, 52 48, 50 48, 52 Ns 44, 68 41, 60 40, 60

Dep.Var. STSS STAI Overall

DTQ

STSS = 9.6 STAI = 43.4

DTQ = 12.0 for age

Overall means are also given. The median age of 65 years are used as a division groups. STSS: Tinnitus severity; STAI: anxiety trait; DTQ; depressive tendency.

It can be seen that no relationship is demonstrated between age and either the STSS or STAI. There is, however, an effect of age on the DTQ, with the younger division of this fairly elderly sample, showing more depressive tendency than those over

386

J. B. S. HALFORD and S. D. ANDERSON

65 yr. Sex has no bearing on STSS values; however, anxiety trait and depressive tendency scores. lXe relationship between Tinnitus Depressive Tendency (DTQ) Variability

females

display

both higher

(TV), Anxiety

Trait (STAI) and

It was noted that Tinnitus Variability did not prove a very discriminating scale on this sample. Although individuals could score from O-4, (i.e. a response range of 5) the median split divided at four or below, with 73% scoring 3 or 4. As shown in Table II, no significant relationship was demonstrated between Tinnitus Variability and the STSS, STAI or DTQ.
TABLE II.-SHOWS CORRELATIONS BETWEEN THE STSS,
THE TWO SUB-SCALES OF THE

STAI,

DTQ,

TV

AND

DTQ PCD 0.17 0.51** (0.71**) 0.52** 0.02 TV 0.07 0.12 0.16 0.19 0.02

STSS STSS STAI 0.28 0.32** 0.32** 0.17 0.07

STAI 0.2s* 0.76** 0.74** 0.51** 0.12

DTQ
0.32** 0.76** (0.96**) (0.71**) 0.16

ID1 0.32** 0.74** (0.96**) 0.52** 0.19

DTQ
ID1 PCD TV

(i) IDI represents most of the DTQ, being items referring to cognitivebehavioural aspects of depression. (ii) PCD refers to actual contact with professionals associated with depression. Bracketed values are spurious being between the DTQ and its own sub-scales. * = one-tailed p < 0.01, ** = one-tailed p < 0.001. STSS: Tinnitus severity; STAI: anxiety trait; DTQ: depressive tendency; IDI: inferential depression items; PCD: professional contact for depression; TV: Tinnitus variability.

The significant correlation between the inferential depression items (IDI) section of the DTQ and the actual professional contact component (PCD), is indicative of the surface validity of the DTQ. The PCD correlates significantly with anxiety. Neither the STSS nor TV are associated with professional contact for depression.
DISCUSSION

The primary finding was a significant association between the severity of the tinnitus defined subjectively, and the two psychological variables of anxiety trait and sub-clinical depressive tendency. Our results suggest that the worse the tinnitus complaint, the greater the likelihood the individual will have a more anxious personality and a tendency to sub-clinical depression. Viewing enduring psychological change as a potential consequence of tinnitus is feasible in this sample, as most had long-term tinnitus. However, one can not make unequivocal causal statements on the basis of non-longitudinal research. In any case it is the authors belief that the relationship between the psychological states of anxiety and depression are associated with tinnitus in a bi-directional fashion. Considering anxiety as a potential product, one can envisage how the presence of an unwanted sound perceived within the ear or head can contribute to tension and cause irritation. Tinnitus patients often complain of interference with quiet recreation and

Anxiety,

depression

and tinnitus

387

relaxation; at its worst making people feel tense and on edge. Frequently persons report difficulty in falling asleep or falling back to sleep, as in the quiet of the night even a minor tinnitus can be aggravating. Equally individuals may complain of the effect of tinnitus on their quality of life, and can become depressed. This can be direct (e.g. reducing enjoyment of quiet recreation) or indirect (e.g. sleeplessness is interfering with job performance and thus self-esteem). Seligmans model of depression 12 1,221 is compatible, as many tinnitus sufferers feel distressed at having a condition beyond their control, and perceive (accurately) that their tinnitus is unlikely to subside. The view that psychological state may exacerbate tinnitus is reinforced by the commonly reported problem, that stress aggravates tinnitus. When tense and anxious, tinnitus like pain, may seem more intolerable. At a physiological level, if an individual is especially anxious, perceptual acuity will be heightened. Unfortunately they will not just hear, see and smell better, but hear their tinnitus better too. The role depressed mood can play, is likely to operate at a cognitive and motivational level. One can not control whether or not one has tinnitus, but one can control or influence the extent to which one attends to it. An individual with a negative cognitive set, is less likely to register what is beneficial in reducing tinnitus primacy, and less inclined to actively explore what may be beneficial. In relation to self-appraisal depression can also lead to selective recall, favouring negative over positive schemata 123, 241. As part of a negative perspective, this may make the depressed individual less likely to: (a) attend to; (b) recall; and (c) focus upon, strategems that may offer relief from tinnitus. For the 60% of the sample for whom age related comparisons could be made, anxiety trait scores were elevated. Small numbers were involved for some age/sex groups. However, for those females in our sample aged 50-69 yr (N = 36), STAI scores were particularly elevated, placing them at the 97th percentile of normal adults. Suitable normative data for the DTQ was unavailable. However, 23 % of the sample reported having seen a psychiatrist with a depressive illness, which would seem to reflect an above average history of depression. One notes that these subjects like Tyler and Bakers 1101, were members of a tinnitus self-help group. It is assumed that membership of such a group is likely to entail a sample of individuals with a more severe form of tinnitus than the general tinnitus population and/or a greater degree of psychological problems, reflecting either pre-tinnitus personality or anxiety and depression brought on by tinnitus. The relationship between the degree of tinnitus severity, anxiety and depression is a complex one. We should remember that although potentially related, these are three separate variables. The STAI and DTQ scores here reflect anxiety trait and depressive tendency both associated with tinnitus and non-associated. Thus these psychological variables correlate with the STSS at low magnitude, albeit to a highly significant extent. The separate Tinnitus Variability (TV) measure did not relate to any of the psychological or tinnitus variables. In particular the prediction that increased variability would lead to a heightened cognitive focus, and hence more anxiety and depression was not proven. Either there is no linear relationship between these concepts or scale limitation was responsible. With the majority of subjects gaining maximum or nearmaximum score, on this sample the scale was not sensitive enough to adequately test the hypothesis.

388

J. B. S. HALF~RD and S. D. ANDERSON

Despite the overall elderly nature of the sample, age-related mental health differences manifested themselves. With no effect on anxiety, depressive tendency was lower in those over 65, which is in keeping with research showing that mental wellbeing increases with age [16]. The higher scores on the DTQ for females, is in agreement with a large general practice study [251, which found a higher prevalence of depression in females; and with research using a psychiatric sample [261. Our females with tinnitus scored higher on anxiety trait than their male counterparts. Spielberger [131 reports similar findings in college students and military recruits, but no such sex differences in high school students or working adults.
CONCLUSION

Tinnitus severity measured by a subjective scale was significantly associated with elevated anxiety trait and depressive tendency. However, the low level of direct correlation between these variables underlines the point that although some of the anxiety and depression in this sample was tinnitus-related, much was not. It is considered that the causal relationship between these psychological variables and tinnitus severity, is likely to be bi-directional but that no definite conclusions can be drawn from non-longitudinal research. A prospective project on psychological trait and ongoing tinnitus development has been incorporated into an existing longitudinal study on hearing and related disorders, at the Institute of Hearing Research [271. The extent to which pre-existing personality factors may predispose an individual to poor adaptation to tinnitus; versus the role that tinnitus plays in causing anxiety and depression will hopefully become clearer from this studys findings. However it will be a great many years before this project reaches completion.
Ackr~o~~lrdgemenfs-This study was supported by the Ian Mactaggart Trust, with facilities provided by the Cromwell Hospital. We also would like to pay tribute to the late John Brown, and express our thanks to his wife, both of whom helped in gaining data from members of the Basildon Branch of the British Tinnitus Association.

REFERENCES 1. HAZELL JWP. Editor. Tin&us. Edinburgh: Churchill Livingstone, 1987. 2. OFFICE OF POPULATION CENSUSES AND SURVEYS, General Household Survey. The Prevalence of Tinnitus 1981. London: OPCS Monitor. GHS 8311, OPCS, 1983. 3. LESKE MC. Prevalence estimates of communicative disorder in the US: language, hearing and vestibular disorders. Asha 1981; 23: 229-237. 4. SMITH P, COLES R. Epidemiology of tinnitus: an update. In: Proceedings ofthe Third International Tinnitus Seminar (Edited by FELDMANN H) pp. 147-153. Karlruhe: Harsch 1987. 5. MEIKLE M, TAYLOR-WALSH E. Characteristics of tinnitus and related observations in over 1800 tinnitus clinic patients. In Proceedings of the Second International Tinnitus Seminar, (Edited by SHULMAN A). J Lar.~n~ol Otol Sup 1984; 9: 17-21. 6. VERNON J. Assessment of the tinnitus patient. In Hazell, JWP op. cit. 1987; 59-72. 7. STEPHENS RDG, HALLAM RS. The Crown-Crisp Experiential Index in patients complaining of tinnitus. Br J Audio1 1985; 19: 151-158. 8. HALL-AM RS, RACHMAN S, HINCHCLIFFE R. Psychological aspects of tinnitus. In: Contributiom to Medical Psychology, (Edited by RACHMAN S). Vol. 3, pp. 31-50. Oxford: Pergamon Press, 1984. 9. REICH GE, JOHNSON RM. Personality characteristics of tinnitus patients. J Laryngol Otol 1984; Suppl. 9: 228-232. 10. TYLER RS, BAKER LJ. Difficulties experienced by tinnitus sufferers. J Speech Hear Dis 1983; 48: 150-154. I I KIRSCH CA, BLANCHARD EB, PARNES SM. Psychological characteristics of individuals high and low in their ability to cope with tinnitus. Psychosom Med 1989; 51: 209-217.

Anxiety,

depression

and tinnitus

389

and 12. HALFORD JBS, ANDERSON SD. Tinnitus severity measured by a subjective scale, audiometry clinical judgement. J Laryngol Ofol 1991; 105: 89-93. 13. SPIELBERGER CD, GORSUCH RL, LUSHENE R, VAGG PR, JACOBS GA. Manual for the State-Trait Amiery fnventory (Form Y). Palo Alto: Consulting Psychologists Press, 1983. data on undergraduate samples. 14. Authors unpublished scale. Acra Psychiat Scand 1983; 1.5. ZIGMOND AS, SNAITH RP. The Hospital Anxiety and Depression 67: 361-370. 16. CASSILETH BR, LUSK EJ, STROUSE TB, MILLER DS, BROWN LL, CROSS PA, TENAGLIN AN. (1984) Psychosocial status in chronic illness: a comparative analysis of six diagnostic groups. N Engl J Med 1984; 311: 506-511. in Parkinsons disease: a quantitative and 17. GOTHAM A-M, BROWN RG, MARSDEN CD. Depression qualitative analysis. J Neural Neurosurg Psychiat 1986; 49: 381-389. and disability 18. BROWN RG, MACCARTHY B, GOTHAM, A-M, DER GJ, MARSDEN CD. Depression in Parkinsons disease: a follow-up of 132 cases. Psycho/ Med 1988; 18: 49-55. of a rating scale for primary depressive illness. B J Sot Clin Psycho1 19. HAMILTON M. Development 1967; 6: 278-296. Third 20. AMERICAN PSYCHIATRIC SOCIETY. Diagnostic and Statistical Manual of Mental Disorders, Edition. Washington DC: American Psychiatric Society, 1987. In The Psychology ofDepression: Conrem21. SELIGMAN MEP. Depression and learned helplessness. porary Theory and Research, (Edited by FRIEDMAN RJ and KATZ MM), pp. 83-125. Chichester: Wiley, 1974. in humans: critique and 22. ABRAMSON LY, SELIGMAN MEP, TEASEDALE JD. Learned helplessness reformulation. J &norm Psychol 1978; 87: 49-74. and self-reference in clinical depression. J Abnorm 23. DERRY PA, KUIPER NA. Schematic processing Psycho1 1981; 90 286-297. to depression: An investigation of two hypotheses. 24. TEASEDALE JD, DENT J. Cognitive vulnerability Br J Clin Psycho1 1987; 26: 113-126. 25. DUNN G, SKUSE D. The natural history of depression in general practice: stochastic models. Psycho1 Med 1981; 11: 755-764. depression scale scores of 26. COOPER BH, FOUTY HE, WURTZ PJ BURDICK BM. Zung self-rating psychiatric outpatients by age and sex. Psychof Reporrs 1988; 62: 259-262. 1989. 27. COLES RRA. Pers. commun.

APPENDIX Depressive Tendency Questionnaire (DTQ) items

Questions l-28 are Inferential Depression Items (IDI). Questions 29-34 represent Professional Contact for Depression (PCD). Question 35 is included in DTQ total score but excluded from PCD. Questions: 12, 14, 15 excluded from scoring, as related to general health. The scoring response is bracketed. 1. Have the last three years largely been very happy ones? (No) 2. Is it common for you to wake up in the morning feeling unhappy? (Yes) 3. Is it unusual for you to be sad all day? (No) 4. Do you cry quite often? (Yes) 5. Have you ever thought that basically, people are selfish and rather unkind? (Yes) 6. Do you think that deep down most people are nice? (No) 7. Have you ever thought that there is little point, in you yourself living? (Yes) 8. Are you glad to be alive? (No) 9. Do you often think about your own death, or the idea of your no longer existing? (Yes) 10. Have you ever contemplated suicide? (Yes) 11. Have you ever tried to kill yourself? (Yes) 12. Do you usually sleep well without drugs or alcohol? (No) 13. Have you ever had difficulty in sleeping, persisting over several weeks, while you were unhappy? (Yes) 14. Would you say that you were reasonably fit, most of the time? (No) 15. Do you worry about poor health? (Yes) 16. When you are feeling unhappy does your interest in sex diminish? (Yes) 17. Have you ever totally lost the desire for sexual relations during an unhappy period? (Yes) 18. Have you ever lost the desire for food when you were unhappy? (Yes)

J. B. S. HALFORD and S. D. ANDERSON 19. Do you think you are a fairly likeable person? (No) 20. Do you often think, that people dont find you interesting company? (Yes) 21. Have you ever thought, you were not a nice person? (Yes) 22. Do you think, that most people find you enjoyable to be with? (No) 23. Do you think that you get more love and friendship than you deserve? (Yes) 24. Do you feel dissatisfied at the way you come across; are you not content with the impression you make on people? (Yes) 25. When you are unhappy, do you ever decide you would prefer to be on your own? (Yes) 26. When you are unhappy, do you ever sit and not speak to others present, because to talk seems an incredible effort? (Yes) 27. Do you prefer to be with people, instead of being by yourself, when you are unhappy? (No) 28. When you are feeling unhappy, have you ever stayed in bed for most of the day, because you could not face people? (Yes) 29. Have you ever been to see your family doctor (GP) because you were depressed? (Yes) 30. Have you ever seen a psychiatrist, with depression as one of your major problems? (Yes) 31. Have you ever been seen by another form of therapist (e.g. analyst, counsellor, psychologist or psychotherapist) when you were depressed? (Yes) 32. Have you ever received inpatient treatment in a hospital, for depression? (Yes) 33. Have you ever been prescribed sleeping tablets, to help you sleep, when you were unhappy? (Yes) 34. Have you ever rung a telephone help service because you were depressed? (Yes) 35. Have you ever thought that you could have done with some form of help from some form of professional, because you were feeling depressed? (If yes, tick Yes regardless of whether you took action or not) (Yes).
Subjective Tinnitus Severity Scale (STSS) items

The scoring

response

is bracketed.

1. Does your tinnitus sometimes make it difficult for you to concentrate? (Yes) 2. Are you almost always aware of your tinnitus? (Yes) 3. Do you find that your tinnitus bothers you, when you are doing something physical, like dressing or gardening? (Yes) 4. Does your tinnitus cause you problems in getting off to sleep? (Yes) 5. Would you say that generally your tinnitus does not bother you? (No) 6. Do you sometimes go for hours without noticing your tinnitus? (No) 7. Is your tinnitus very noisy? (Yes) 8. Does your tinnitus frequently upset you? (Yes) 9. Do you often have a day or more completely free from tinnitus? (No) 10. When you are busy, do you quite often forget about your tinnitus? (No) 11. Is your tinnitus present for at least part of every day? (Yes) 12. Does your tinnitus often interfere with your ability to relax? (Yes) 13. Would you say, that although your tinnitus can be irritating, it does not get you down? (No) 14. Do you often talk about the problems your tinnitus causes to others? (Yes) 15. Is it unusual for your tinnitus to annoy you, when you are trying to read or watch television? (No) 16. Would you say that, you would have a much more enjoyable life, if you did not have tinnitus? (Yes)
Tim&us Variability items

The scoring 1. 2. 3. 4.

response

is bracketed (Yes)

Do you have periods when your tinnitus is much worse than it usually is? (Yes) Are there times, when you hear your tinnitus, but it seems much quieter than usual? Does your tinnitus vary in loudness? (Yes) Does the sound of your tint&us change, other than in loudness (e.g. in tone)? (Yes)