Practitioners in the disciplines of rehabilitative audiology and clinical psychology find themselves in each other's neighborhood as regards the phenomenon of tinnitus. As a disorder, tinnitus is generally unresponsive to direct forms of intervention using pharmacological or physical agents.
By contrast, some success is observed following hearing aid fitting1,2 or following a course of cognitive-behavior therapy (CBT). Andersson and Lyttkens provide a useful summation of research using CBT and other forms of psychological treatment.3
Critical to any form of treatment for tinnitus is the reliance placed on measures to assess the effectiveness of the intervention. The purpose of this paper is to review a range of available tinnitus self-rating scales, in particular to describe: (1) their domains of coverage and (2) their psychometric properties.
It is of practical value to indicate these two features. Clinicians need to have confidence that a measurement device assesses in the domains that an intervention is designed to address and that the device is “well-behaved” in terms of its factor structure and test-retest reliability. The latter feature is especially important for calculating the likelihood that any change in a self-assessed quality is not simply due to measurement error.
Not all the scales included here have been tested on factor structure and test-retest stability (one or two have included neither); more attention will be given to scales in which both features have been covered.
Tinnitus is essentially a self-report phenomenon. Most typically it is not manifest to others except by complaints from the one who suffers it. In contrast, loss of hearing is often complained of by others before it is acknowledged by the affected person.4,5 And, while there is a fairly orderly relationship between self-assessed and performance-based measures of hearing ability, it is often difficult to see a link between rated severity of tinnitus and matched loudness level.6
The first systematic self-report study of tinnitus appears to be that of Tyler and Baker,7 who used the open-ended question technique of Barcham and Stephens8 to find out what sorts of difficulties people experienced with tinnitus. The outcome of that study has informed the design of much of the subsequent research aimed at developing more structured self-assessment scales.
In Tyler and Baker's study, tinnitus was reported as generating disabling effects on hearing, including distortion and audibility problems, and even as having effects on spatial hearing (sound localization, and the like). Just as critically, tinnitus was reported as interfering with sleep and causing both emotional distress and ill-effects on general health. This study, and the main features of the body of research following from it, are reviewed in Noble.9 The aim of the present paper is more confined than that review. It is to examine the small number of tinnitus self-assessment devices whose psychometric properties are known in greater or lesser part.
FORMAL SELF-ASSESSMENT SCALES
Disabilities and handicaps due to tinnitus
The first four devices described here are oriented to assessing the severity of tinnitus in terms of disabilities and handicaps, where disabilities may be identified as the direct effects of tinnitus on hearing, and handicaps as the personal and social disturbances that the person experiences due to tinnitus. The fifth scale makes reference to the reactions of others to the person with tinnitus, and is thus concerned with an issue somewhat different from the clinical mainstream.
Tinnitus Effects Questionnaire (TEQ)
This measure was developed by Hallam, Jakes, and Hinchcliffe10 on the basis of clinical observations, together with what was known from earlier studies by Tyler and Baker7 and Hallam, Rachman, and Hinchcliffe.11 The questionnaire comprises 51 items, 34 of which form three primary factors: disturbance of sleep and relaxation, emotional distress, and hearing difficulties. The remaining items cover a range of ancillary issues. Henry and Wilson report test-retest reliability for this scale (6–8 weeks inter-test interval) of 0.91.12 The study by Henry and Wilson and a study reported by Hiller and Goebel13 using a German version of the TEQ confirm the distinguishability of factors in the TEQ, but the items cluster somewhat differently from the original.
Tinnitus Handicap Questionnaire (THQ)
Kuk, Tyler, Russell, and Jordan14 devised this scale directly on the basis of the set of responses of tinnitus sufferers to the Tyler and Baker7 open-ended question. From an initially large pool of statements, a 27-item scale was derived comprising items with a broad range of scores and which contributed more strongly to the internal consistency of the scale, as reflected in the level of Cronbach's alpha. Items were also excluded that clustered with other ones covering similar domains. This scale was completed by 275 people presenting with tinnitus. The main factor of the THQ addresses a mix of social, emotional, and rest/sleep problems. A second, smaller factor covers interference with hearing function. A third factor is harder to label, and the items in question are not closely related to the rest of the scale. Henry and Wilson confirmed this factor structure and also found test-retest correlation (6–8 weeks inter-test interval) of 0.84.12
Tinnitus Severity Scale (TSS)
Sweetow and Levy15 designed this 15-item inventory to reflect five categories in which tinnitus is known to have effects, on the basis of the earlier study by Tyler and Baker7 and one reported by Jakes et al.16 The categories are: intrusiveness, distress, hearing loss, sleep disturbance, and medication. Some of these categories are represented by a single item. No psychometric analyses are available.
Subjective Tinnitus Severity Scale (STSS)
This 16-item scale is described by Halford and Anderson17 as designed to achieve a single factor structure assessing “severity” of tinnitus—defined in terms of how intrusively it is experienced, how much it interferes with sleep and relaxation, and how distressing it is. No actual factor structure was determined for the STSS, nor its retest reliability.
Tinnitus Handicap/Support Scale (TH/SS)
This scale, devised by Erlandsson, Hallberg, and Axelsson,18 goes to the attitudes of family and friends toward the person with tinnitus. The TH/SS comprises 28 items forming three factors of similar weight: reactions of others (largely negative), support from others, and personal and social handicaps due to tinnitus.
Psychological reactions to tinnitus
The next device (Tinnitus Reaction Questionnaire-TRQ) gives more specific focus to the response of the person to the fact of tinnitus as a feature of life. As explained in the next paragraph, this reflects a shift in how the problem of tinnitus may be managed clinically. The THI, described thereafter, addresses something of that issue, as well as elements of the foregoing ground covered by the TEQ and THQ.
Tinnitus Reaction Questionnaire (TRQ)
Wilson, Henry, Bowen, and Haralambous19 developed this scale specifically to assess psychological aspects of tinnitus, in particular the nature and extent of distress caused by tinnitus. The focus on psychological responses to the tinnitus experience represents the maturation of a trend seen in some of the earlier literature, namely, to give greater attention to how the person copes with tinnitus noise, as opposed to how to assess the severity of the tinnitus as such (see also Noble20). This change of emphasis may be witnessed as a practitioner/researcher response to the growing evidence that tinnitus does not (or not readily) yield to medicinal or other physical interventions. Finding some means to enable people to cope with the disorder more effectively offers a potentially useful therapeutic approach, hence the increasing involvement of clinical psychologists in its management.
The TRQ is based mainly on the Tyler and Baker data,7 with some additional items suggested by the authors' clinical experience. The 26-item scale covers various elements of personal and social handicap due to tinnitus (anger, despair, helplessness, intrusiveness, activity avoidance). The scale was trialed in 156 people presenting with tinnitus, 43 of whom were re-tested, most typically after 3 weeks. Retest scores correlated with initial scores 0.88. Four factors were observable in the data, the primary one reflecting “general distress” (anger, annoyance, helplessness, despair); the second, interference with work and leisure; the third, partly overlapping the second, but including more severe signs of distress (crying, sleep problems, feelings of being driven mad). The fourth factor was on avoidance of activity. From other assessments and psychological tests it was found that TRQ scores were more closely related to anxiety and depression than to neuroticism, and were correlated with independent ratings of low coping skill.
Tinnitus Handicap Inventory (THI)
Newman, Jacobson, and Spitzer21 developed this 25-item scale to remedy supposed shortcomings in existing ones. Although no factor analysis was undertaken, the authors group items in the THI under three headings: functional (a mix of intrusiveness and limitation on activities); emotional (distress, annoyance, etc.), and catastrophic (desperation, helplessness). The three subscales showed high levels of inter-correlation. A test-retest study in 29 people for whom tinnitus was the major complaint is reported by Newman, Sandridge, and Jacobson.22 This yielded a correlation of 0.92 for the scale as a whole, and a critical difference of 20 points (total scale score is 100) was identified as required for clinically significant change in an individual case. Retest was conducted on average 20 days after initial test, but with a very large range of inter-test intervals.
Zachariae et al. applied a Danish form of the THI in 50 patients presenting with tinnitus as the main complaint.23 Their factor analysis did not confirm the three original subscales, and those authors raise a question mark over the distinctness of the original item groupings.
One of the most interesting developments in tinnitus self-assessment, and one with substantial implications for clinical management, is represented by the next two scales. These appear to have been developed quite independently of each other, so it is all the more significant that their content and performance converge; hence, in a real sense, each scale validates the other.
Tinnitus Coping Style Questionnaire (TCSQ)
Budd and Pugh24,25 devised this 33-item scale to assess what they term maladaptive vs effective ways of coping with tinnitus, on the model of coping with chronic pain. The original factor analysis24 suggested three factors (the third labeled “passive” coping). This solution was not confirmed in their second study,25 involving 108 people referred to a tinnitus clinic; the above two-factor outcome emerged instead.
The maladaptive style involves preoccupation with the tinnitus, magical thinking about its disappearance, fears of going mad, hopelessness, and the like. The effective style involves seeing life as worthwhile despite tinnitus, engaging in distracting activity, focusing on other features of life.
The two factors were found to be uncorrelated; inter-subject variation in use of one style is unrelated to variation in use of the other. And the first style, but not the second, was related to measures of depression and anxiety, and to subjective ratings of tinnitus severity. (Here we need to recall that subjective loudness rating of tinnitus is routinely found not to correlate with matched loudness, supporting the idea that “subjective loudness” is a surrogate for “oppressive awareness.”20)
Mirz et al. found that the maladaptive subscale of the TCSQ featured as a significant variable in regression analyses on visual analogue estimates of loudness, annoyance, and intrusiveness of tinnitus.26 Zachariae et al.23 found that the maladaptive subscale, but not the effective subscale, correlated with the THI.21
Tinnitus Cognitions Questionnaire (TCQ)
This scale, developed by Wilson and Henry,27 is also based on variations in coping style on the model of chronic pain. The TCQ comprises 26 items, half of which describe negative thoughts in connection with tinnitus, half positive. While the detailed wording of the items differs from that of the TCSQ, the themes, both negative and positive, are very similar to the maladaptive and effective subscales of that device. The factor structure of the TCQ divides cleanly between the negative and positive thoughts items; both sets correlate similarly with total score; the two sets are unrelated to each other; and the negative subset correlates more closely than the positive with measures of depression. These outcomes parallel the independent findings of Budd and Pugh with the TCSQ.24,25 Test-retest statistics remain to be reported for both the TCSQ and TCQ, but on the evidence of other tinnitus self-rating devices it can be expected their performance will be stable.
For clinicians interested in assessing disabilities and handicaps, the earliest measures, particularly the Tinnitus Effects or the Tinnitus Handicap Questionnaire, seem to be suited to the task. Given the more recent directions in psychological management of tinnitus effects, particularly the possible role of different coping styles in influencing the level of experienced handicap, the more recent inventories (TCSQ, TCQ) are clearly also relevant to the assessment task.
It remains to be observed whether effects of tinnitus in the handicap domain can be mediated by training in the use of more effective coping style. If that is possible, it may enable sufferers to live less desperately with the disorder and to function better in spite of the noises. In view here is a prospect that cognitive-behavioral intervention on the part of the clinical psychologist, either separately or in conjunction with the use of amplification managed by the audiologist, might make a difference in the lives of some of the people who present with this intractable chronic problem.
These observations go to a larger point, of the sort made by Wilson et al.28 Any responsible approach to the clinical management of tinnitus needs to be based on well-established theoretical and evidentiary grounds. There is always a risk that the magical thinking that occurs in maladaptive coping with tinnitus is matched by magical thinking on the part of clinicians concerning what represents effective treatments. The graveyard is littered with treatment offerings that do not work. Yet promises are still held out to sufferers about the efficacy of treatment regimes for which there is no secure theory or evidence.
By contrast, cognitive behavior therapy is now well established in numerous domains where psychological management of chronic conditions is called for, and, as noted in the introduction, there is a body of evidence supporting its (admittedly limited) effectiveness in the way it has been deployed so far in the treatment of tinnitus. With the recent evidence about the influence of coping style, refinement of the CBT approach may improve that effectiveness further.
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