Mean scores across the complete dataset for each TCQ item were calculated. The items with the highest mean scores were items: 1, “if only the noise would go away” (M = 2.60, SD = 1.20); 11, “my tinnitus is never going to get better” (M = 2.56, SD = 1.32); and 6, “if only I could get some peace and quiet” (M = 2.39, SD = 1.31). The lowest mean scores were obtained by items: 12, “the noise will overwhelm me” (M = 1.32, SD = 1.24); 3, “what did I do to deserve this?” (M = 1.03, SD = 1.28); and 13, “with this noise, life is not worth living” (M = 0.58, SD = 1.02).
The overall mean TCQ score was 43.86 (SD = 17.20). Mean scores for the total TCQ and for the two subscales according to “problem category” are shown in Table 3.
A one-way between groups ANOVA was conducted to explore the effect of problem category on mean score on the TCQ using Bonferroni correction for multiple comparisons. For the negative subscale, there was a statistically significant difference across the five problem categories [F(4,337) = 143.58, p < 0.001]. In fact, post-hoc comparisons using the Tamhane T2 test indicated that the differences between mean scores were statistically significant (p < 0.05; corrected) for all problem groups.
For the positive subscale, there was a statistically significant difference across the five problem categories [F(4,336) = 7.47, p < 0.001]. However, post-hoc comparisons using the Tamhane T2 test indicated that the differences between mean positive scores were only statistically significant for the “no problem” group (M = 28.40, SD = 17.11) compared with the “moderate problem” group (M = 18.55, SD = 8.64, p = 0.02) and for the “moderate problem” group compared with the “very big problem” group (M = 26.79, SD = 11.66, p = 0.002).
Overall, there was a statistically significant difference in total TCQ scores for the five problem categories [F(4,336) = 7.47, p < 0.001]. Post-hoc comparisons using the Tamhane T2 test indicated that the mean total score for the “no problem” group (M = 31.17, SD = 16.03) was not significantly different from the mean total score for the “small problem” group (M = 34.00, SD = 12.44, p = 0.99). Mean scores for all other groups were significantly different (p < 0.05; corrected).
The findings of this study have contributed to knowledge about the type and frequency of thoughts people have relative to the severity of their tinnitus, as well as providing support for the use of the TCQ in tinnitus research and clinical practice.
The TCQ has previously only been validated in 200 Australian individuals, some of whom were clinic patients and some of whom were volunteers (Wilson & Henry 1998). Our findings, which came from a somewhat larger UK-based nonclinical population, were broadly similar to those of the original study. The overall mean TCQ score was equivalent to that of Wilson and Henry’s mixed population (M = 47.16; SD = 12.71). The same three items (1, 6, and 11) had the highest mean scores, suggesting frequently wishing to be free of the noise, longing for peace, and quiet but despairing of this possibility seem to be common ways of thinking. Few people in either study reported thinking that “life is not worth living” with tinnitus (item 13); one might expect this item only to apply to those experiencing the very greatest distress. Both studies found the positive and negative subscales to be uncorrelated. Factor analysis also found the proposed two-factor structure to have good psychometric properties in this population. Very high internal consistency suggests that there may be some redundant items and the TCQ could potentially be reduced to a smaller number of items.
In the present study, the lowest mean score on the positive subscale (indicating a greater number of and/or more frequent positive thoughts) was obtained by the “moderate problem” group, while the “very big problem” group scored relatively high on this subscale. It may be that positive thinking is a strategy deliberately used by people to better cope with troubling tinnitus or that people who class tinnitus as a “moderate problem” switch between negative and positive thinking, perhaps depending on mood or environment. It is likely that those people who class tinnitus as a “very big problem” are simply unable to engage in positive thinking most of the time, although some positive thinking is still occurring in this group. These observations and the lack of correlation between positive and negative subscales suggest that positive thoughts do not “cancel out” negative ones. Similar findings were reported by Budd and Pugh (1996), who found that “effective coping” was not associated with lower distress, whereas “lack of maladaptive coping” was. The indication here is that positive thinking is not characteristic of nonbothersome tinnitus, whereas lack of negative thinking is.
The findings of the present study have some important implications for therapy. Here, we found that people who rate their tinnitus as a “moderate problem” are able to think positively about it at least some of the time. This is something that can be built on during counseling. People with very problematic tinnitus may need more intensive help to change their thinking. It is notable that Conrad et al. (2015a) found that participants who engaged in the most catastrophic thinking had poorer outcomes than others after clinician-guided internet-based CBT but not after face-to-face CBT. Here, face-to-face therapy allowed for more intensive therapeutic discussion, possibly explaining the difference. From any starting point, becoming a member of the “not a problem” group is clearly the most desirable outcome of therapy. To be like members of this group, our findings indicate that people need to learn to stop thinking about their tinnitus altogether. Deliberately replacing negative thoughts with more positive ones may or may not be part of this transition. Significant reductions in tinnitus-related emotional distress have been demonstrated in several studies, which involve cognitive restructuring exercises (Henry & Wilson 1996; Hiller & Haerkotter 2005; Cima et al. 2012; Conrad et al. 2015a), but it is unclear how much of a contribution such exercises make to overall improvement above other things such as attention-shifting or behavior change. It is also as yet unknown whether still greater improvements might come about through mindful meditation, during which people learn to disengage with their thoughts altogether (Williams et al. 2007). Results of ongoing trials may help to answer how such psychological therapies bring about patient benefit.
A limitation of the present study is that only people from the general population were tested. Validation of the TCQ using clinical populations is an important next step. A limitation of the TCQ itself is that the thoughts it lists, although derived from patient interviews, it do not appear to have been selected through a systematic process. Other measures of tinnitus-related thinking are adapted from pain cognition scales (Flor & Schwarz 2003; Cima et al. 2011) and were not developed with tinnitus patients in mind. We do not yet have sufficient knowledge of how people with tinnitus think about it. Surveys and qualitative interview studies would help to build a more accurate picture.
L.E.H. is funded by the British Tinnitus Association. D. A. H. and D. J. H. are funded by NIHR Biomedical Research Unit program; however, the views expressed in this article are those of the authors and not necessarily those of the NIHR, the NHS, or the Department of Health.
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WORLD HEARING DAY: 3 MARCH 2017
ACTION FOR HEARING LOSS: MAKE A SOUND INVESTMENT
The World Hearing Day is an annual advocacy event, coordinated by the World Health Organization (WHO). It is observed on 3rd March each year and aims to raise awareness on hearing loss and promote actions for ear and hearing care across the world. The day is marked by a different theme each year and accompanied by evidence-based advocacy tools and messages, which are released by WHO. A large number of individuals, organizations and governments have joined this effort in order to advocate for prioritization of hearing care.
The theme for 2017 is ‘Action for hearing loss: make a sound investment’. This will focus on the economic aspects of hearing loss and cost effectiveness of interventions to reduce its prevalence and impact.
Information products and advocacy materials will be made available by WHO on its webpage http://www.who.int/pbd/deafness/world-hearing-day/en/. WHO invites all stakeholders in the field of ear and hearing care to undertake activities to mark this day and join this global initiative.