- Email: [email protected]
Tinnitus and insomnia
Original Contributions Tinnitus and Insomnia Robert L. Folmer, PhD, and Susan E. Griest, MPH Purpose: To investigate the effects of insomnia on tinnitus severity and to determine how this relationship may evolve with the passage of time. Materials and Methods: Questionnaires were mailed to patients before their initial appointment at the Oregon Health Sciences University Tinnitus Clinic between 1994 and 1997. These questionnaires requested information pertaining to insomnia, tinnitus severity, and loudness. During their initial appointment, patients received counseling, education, and reassurance about tinnitus; audiometric and tinnitus evaluations; and treatment recommendations. Follow-up questionnaires were mailed to 350 patients 1 to 4 years (mean ⫽ 2.3 yr) after their initial appointment at the clinic. Results: One hundred seventy-four patients (130 men, 44 women; mean age 55.9 yr) returned follow-up questionnaires. Although many of these patients improved in both sleep interference and tinnitus severity, a significant number (43) reported on the follow-up questionnaire that they continued to have difficulty sleeping. Reported loudness and severity of tinnitus were significantly greater for this group than for groups of patients who reported that they never or only sometimes have difficulty sleeping. The relationship between sleep disturbance and tinnitus severity became more pronounced with the passage of time. Conclusions: Insomnia is associated with greater perceived loudness and severity of tinnitus. These findings underscore the importance of identification and successful treatment of insomnia for patients with tinnitus. (Am J Otolaryngol 2000;21:287-293. Copyright r 2000 by W.B. Saunders Company)
Tyler and Baker1 asked patients to list the difficulties they experienced as a result of their tinnitus. The most frequently listed difficulty was ‘‘getting to sleep,’’ a complaint reported by 41 (56.9%) of the 72 respondents. Jakes et al2 and Axelsson and Ringdahl3 also reported that insomnia was the problem most frequently mentioned by patients with tinnitus. Sanchez and Stephens4 mailed Tyler and Baker’s1 questionnaire to 436 patients who were scheduled to visit the Tinnitus Clinic of the Welsh Hearing Institute at the University Hospital of Wales in Cardiff, England. Sleep From the Tinnitus Clinic, Oregon Hearing Research Center, Department of Otolaryngology, Oregon Health Sciences University, Portland, OR. Address reprint requests to Robert L. Folmer, PhD, Oregon Hearing Research Center, NRCO4, 3181 SW Sam Jackson Park Rd, Portland, OR 97201-3098. Copyright r 2000 by W.B. Saunders Company 0196-0709/00/2105-0001$10.00/0 doi:10.1053/ajot.2000.9871
difficulty was the second most common complaint, listed by 25% of the respondents. Hearing problems, the most common difficulty, was mentioned by 30% of the patients. Hallam et al5 reported that the 3 main areas of complaint identified by 79 tinnitus patients at a neuro-otology clinic were emotional distress, hearing difficulties, and sleep disturbance. Hallam6 estimated that approximately 50% of tinnitus patients experience disturbances of the normal sleep pattern. In their study of tinnitus severity, Meikle et al7 analyzed responses to questionnaires from more than 1,800 patients who attended the Tinnitus Clinic at Oregon Health Sciences University. There was no correlation between self-rated tinnitus severity and the loudness, type, quality, or pitch of tinnitus sounds heard by patients. However, tinnitus severity ratings were highly correlated with sleep disturbance. Axelsson and Ringdahl,3 Scott et al,8 Erlandsson et al,9 and Alster et al10 also reported that
American Journal of Otolaryngology, Vol 21, No 5 (September-October), 2000: pp 287-293
287
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tinnitus was more severe in patients who experienced insomnia. It is clear that sleep disturbance is a major problem for many people with tinnitus. The goal of the present study was to investigate the effects of insomnia on tinnitus severity and to examine how this relationship may evolve with the passage of time. Ultimately, we hope that this information will (1) be used for developing and implementing effective treatment programs and (2) contribute to the development and refinement of diagnostic and assessment procedures for tinnitus. METHOD Detailed questionnaires were mailed to patients before their initial appointment at the Oregon Health Sciences University Tinnitus Clinic between 1994 and 1997. These questionnaires requested information about patients’ medical, hearing, and tinnitus histories.11-12 The initial appointment at the clinic had the following format (many of these procedures were described by Johnson12): (1) Patients met with staff members for an in-depth interview and review of their medical, hearing, tinnitus, and psychosocial histories and conditions. Patients received information about possible causes of their tinnitus as well as reassurance and counseling regarding factors that could exacerbate or improve their condition. (2) Audiological evaluations that included puretone air and bone conduction thresholds, speech perception in quiet and noise, maximum comfort level/uncomfortable loudness level, and tympanometry. (3) Tinnitus evaluations that included matching tinnitus to sounds played through headphones, determination of minimum masking levels, and measurements of residual inhibition. (4) Evaluations of acoustic therapies—based on the patient’s audiological evaluations, various devices would be demonstrated. These could include hearing aids, (in-the-ear sound generators), tinnitus instruments (combinations of hearing aids and sound generators), tabletop sound generation machines, masking tapes, or CDs. (5) Review of the results of evaluations, presentation of treatment plan, and other recommendations. Follow-up questionnaires were mailed to 350 patients 1 to 4 years (mean ⫽ 2.30 ⫾ 0.76 yr) after their initial appointment. Figure 1 contains a copy of the follow-up questionnaire. These questions were also asked in the initial questionnaires. Questions 1 through 11 constitute a Tinnitus Severity Index13,14 (TSI) which assesses the negative impacts
FOLMER AND GRIEST
of tinnitus on patients. Numerical responses to questions 1 through 11 were added together to give a total TSI score for each patient. Data relating to patient demographics, audiometric thresholds, reported tinnitus loudness, and reported sleep disturbance were analyzed for patients who returned follow-up questionnaires.
RESULTS One hundred seventy-four patients (130 men, 44 women) returned follow-up questionnaires. This higher percentage of men is consistent with the usual percentage (⬎70%) of men seen in this clinic. Table 1 contains grand averaged pure-tone air conduction thresholds and standard deviations for all 174 patients. This pattern of high-frequency sensorineural hearing loss is typical for our patient population. For the remaining analyses of initial and follow-up questionnaires, patients were divided into 3 groups based on their response to question 12: ‘‘Does your tinnitus interfere with sleep?’’ Table 2 contains the numbers of patients who answered ‘‘no,’’ ‘‘yes, sometimes,’’ or ‘‘yes, often’’ to this question. The net improvement in sleep disturbance from the initial to the follow-up questionnaire was as follows: 11 men and 7 women moved from the ‘‘often’’ group to the ‘‘no’’ group, and 1 woman moved from the ‘‘often’’ group to the ‘‘sometimes’’ group. Comparisons of averaged audiometric thresholds among the ‘‘no,’’ ‘‘sometimes,’’ and ‘‘often’’ groups showed no significant differences on either the initial or follow-up questionnaires; ie, there were no significant differences in hearing loss among groups of tinnitus patients with differing degrees of sleep disturbance. Table 3 contains the mean ages and standard deviations of each group of patients. The age range for patients making their initial visit to the clinic was 17 to 83 years. The age range for patients who returned the follow-up questionnaire was 20 to 85 years. At the time of the patients’ initial appointment, the only significant difference is greater age for those who reported no sleep disturbance than for those who reported that they often have trouble sleeping (P ⫽ .022). There were no significant differences in age among the 3 groups of
TINNITUS AND INSOMNIA
289
Fig 1. Tinnitus severity index questions.
patients who responded to the follow-up questionnaire. Table 4 contains distributions of patients according to the number of years since tinnitus onset at the time of their initial appointment. Greater sleep disturbance is correlated with a higher percentage of patients whose tinnitus began within 2 years of their initial appointment. For example, 33.3% of the patients with no sleep interference had tinnitus that began within 2 years of their initial appointment. This percentage increased to 47.1%
for patients who reported that they sometimes have difficulty sleeping, and it increased to 61.2% for patients who reported that they often experience insomnia. In general, patients with tinnitus that began within 2 years were more likely to experience sleep difficulties than patients who had tinnitus for 3 or more years. Table 5 contains means and standard deviations of reported loudness (on a 1-to-10 scale) of tinnitus for each of the 3 sleep interference groups on both the initial and follow-up ques-
TABLE 1. Grand Averages of Pure-Tone Air Conduction Thresholds of Patients (dB HL) (Hz) Right Ear Left Ear
250
500
1,000
2,000
3,000
4,000
6,000
8,000
14.3 ⫾ 11.2 15.5 ⫾ 14.4
12.9 ⫾ 12.0 14.3 ⫾ 15.4
16.5 ⫾ 14.1 16.5 ⫾ 16.8
21.9 ⫾ 19.7 24.6 ⫾ 21.5
33.1 ⫾ 24.1 36.7 ⫾ 23.9
43.3 ⫾ 25.6 44.8 ⫾ 25.4
46.2 ⫾ 25.0 47.6 ⫾ 24.8
47.9 ⫾ 27.4 50.1 ⫾ 26.5
290
FOLMER AND GRIEST
TABLE 2. Patients’ Responses to ‘‘Does Your Tinnitus
TABLE 4. Years Since Onset of Tinnitus at the Time of
Interfere With Sleep?’’
Initial Appointment vs. Numbers of Patients Reporting Sleep Difficulty Initial
No Sometimes Often Total
Follow-Up
Males
Females
Males
Females
34 52 44 130
8 18 18 44
45 52 33 130
15 19 10 44
tionnaires. Significant differences in reported loudness occurred between the group of patients who often had trouble sleeping and the groups who never or sometimes had sleep disturbance (P ⱕ .0005 for all of these comparisons on both questionnaires). Table 5 also contains means and standard deviations of TSI scores for each of the 3 sleep groups on both questionnaires. One-way analyses of variance indicated that there was a significant difference in TSI scores among the 3 sleep groups on both the initial (F ⫽ 31.0; P ⱕ .0005) and follow-up (F ⫽ 59.5; P ⱕ .0005) questionnaires. Results of multiple comparisons (Scheffe tests) of TSI scores made among the 3 sleep groups are listed in Table 5. In general, TSI scores increased significantly with reported sleep interference on both the initial and follow-up questionnaires. The mean numerical response to almost every TSI question was significantly greater for the ‘‘often’’ group compared with either the ‘‘no’’ or ‘‘sometimes’’ sleep interference groups. The 2 exceptions were ‘‘Does your tinnitus make it harder to interact pleasantly with others?’’ and ‘‘Does your tinnitus interfere with your social activities or other things you do in your leisure time?’’ on the initial questionnaire. There were significant differences in mean responses between the ‘‘no’’ and ‘‘sometimes’’ groups for 5 of the TSI questions (those pertaining to discomfort in a quiet room, feeling TABLE 3. Average Ages of Patients (yrs)
No Sometimes Often Grand Average
Initial
Follow-Up
57.1 ⫾ 11.2 (n ⫽ 42) 54.0 ⫾ 11.0 (n ⫽ 70) 50.7 ⫾ 12.0 (n ⫽ 62) 53.6 ⫾ 11.6
57.7 ⫾ 10.2 (n ⫽ 60) 55.9 ⫾ 12.9 (n ⫽ 71) 53.6 ⫾ 10.8 (n ⫽ 43) 55.9 ⫾ 11.6
No Sometimes Often
⬍1
1-2
3-5
6-10
11-20
⬎20 (yrs)
9 19 23
5 14 15
1 12 6
6 6 4
12 6 8
9 13 6
irritable or nervous, feeling tired or stressed, difficulty relaxing, and usual discomfort experienced) on the initial questionnaire. However, significant differences in responses between these 2 groups of patients were seen for all 11 TSI questions on the follow-up questionnaire. Responses from the ‘‘often’’ sleep interference group were significantly greater than those given by either of the other 2 groups for all 11 TSI questions on the follow-up questionnaire. DISCUSSION Audiometric Thresholds Most of the patients in this study had bilateral high frequency sensorineural hearing loss beginning between 2000 to 3000 Hz. However, pure-tone air conduction thresholds of patients with greater reported sleep interference were not significantly different from thresholds of patients with fewer sleep disturbances. This observation is in contrast to the findings of Alster et al,10 who reported that greater sleep disturbance was correlated with greater hearing loss in their study of 80 tinnitus patients. There are several possible explanations for the differing results of these studies: (1) patients in the study by Alster et al10 were significantly younger (mean age 36 ⫾ 11 yr) than the patients in the present study (mean age 53.6 ⫾ 11.6 yr at the time of their initial appointment); (2) a greater percentage of patients in the study by Alster et al10 were men (95.0% vs 74.7% in the present study); (3) all of the patients in the study by Alster et al10 had been Israeli army personnel, 95% of whom had noise-induced hearing loss (NIHL); (4) the average hearing loss for NIHL patients in the study by Alster et al10 was 46 dB HL in the frequency range between 2 to 8 kHz; the average hearing loss across the same frequency range for patients in the present study
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291
TABLE 5. Means and Standard Deviations of Responses Initial Questionnaire
Reported Loudness of Tinnitus TSI Score Scheffe Comparisons of Reported Loudness Between Groups Pⱕ Scheffe Comparisons of Mean TSI Scores Between Groups Pⱕ
Follow-Up Questionnaire
Group 1
Group 2
Group 3
Group 1
Group 2
Group 3
No (n ⫽ 42)
Sometimes (n ⫽ 70)
Often (n ⫽ 62)
No (n ⫽ 60)
Sometimes (n ⫽ 71)
Often (n ⫽ 43)
5.74 ⫾ 1.89 28.46 ⫾ 8.81
6.23 ⫾ 1.90 33.18 ⫾ 6.60
7.78 ⫾ 1.75 40.09 ⫾ 6.62
5.53 ⫾ 2.26 25.12 ⫾ 7.79
6.17 ⫾ 1.89 31.58 ⫾ 5.94
7.92 ⫾ 1.62 39.93 ⫾ 6.56
1 and 2 .442
1 and 3 .0005
2 and 3 .0005
1 and 2 .184
1 and 3 .0005
2 and 3 .0005
1 and 2 .006
1 and 3 .0005
2 and 3 .0005
1 and 2 .0005
1 and 3 .0005
2 and 3 .0005
was 39.6 dB HL. Any or all of these factors could have contributed to the association between sleep interference and audiometric data observed in each of these studies. Time Since Onset of Tinnitus In the present study, tinnitus that had its onset within 2 years of the patients’ initial appointment was correlated with a greater probability of sleep interference than tinnitus that had been present for 3 or more years (Table 4). Tyler and Baker1 reported that the number of problems experienced by tinnitus patients decreased with increased time since the onset of their tinnitus. Similarly, Scott et al8 reported that their patients’ tolerance to tinnitus increased with time since tinnitus onset. These observations could be part of the reason that patients with recent-onset tinnitus in the present study were more likely to experience sleep interference than patients who had tinnitus for 3 years or more. Increased tolerance to tinnitus over time probably also contributed to the net improvement of sleep patterns experienced by patients from the time of the initial questionnaires to the follow-up questionnaires. Loudness of Tinnitus Patients who often experienced sleep interference in the present study rated their tinnitus as significantly louder (on a 1-to-10 visual scale) than patients who never or sometimes experienced sleep disturbances. This associa-
tion between sleep difficulty and reported tinnitus loudness was also observed by Slater and Terry.15 Meikle et al7 reported that tinnitus severity was not correlated with the matched loudness of the sound. Tinnitus loudness reported on a visual scale might be a better indicator of perceived severity than tinnitus loudness that is matched to a sound presented through headphones. CONCLUSIONS In the present study, greater sleep interference was correlated with greater tinnitus severity. This conclusion is in agreement with the findings of several other studies.3,7-10 Differences in tinnitus severity among the 3 sleep interference groups were more pronounced on the follow-up questionnaire than on the initial questionnaire. A possible explanation for this is that the passage of time—an average of 2.3 years—from the initial to the follow-up questionnaire reduced the influence of earlier tinnitus onset observed on the initial questionnaire. By the time that they completed the follow-up questionnaire, all 174 patients in the present study had experienced tinnitus for more than 1 year, and the average time since the onset of their tinnitus had increased by 2.3 years. According to their responses on the initial and follow-up questionnaires, patients in the present study reported an overall improvement in both sleep interference and tinnitus severity. There were several factors that contributed to these improvements:
292
FOLMER AND GRIEST
1) Patients received information about tinnitus, reassurance and counseling, audiometric and tinnitus evaluations, and treatment recommendations during their initial appointment. 2) Patients implemented recommended treatments including masking tapes or CDs; bedside sound generating machines; in-the-ear sound generators, hearing aids, or combination instruments (combinations of hearing aids and sound generators); relaxation and stress management therapies; psychological counseling; changes in diet (eg, reducing intake of caffeine or alcohol); protecting their ears from excessively loud sounds; massage, exercise, and biofeedback; and medications to improve sleep. Table 6 lists the medications that were taken by patients in the present study for insomnia, depression, and anxiety. In addition to any anxiolytic or antidepressant actions they might have, all of these medications can produce drowsiness and reduce sleep disturTABLE 6. Medications Used by Patients in the Present Study No. of Patients Using Hypnotics Zolpidem (Ambien; GD Searle & Co, Chicago, IL) Anxiolytics/Sedatives Alprazolam (Xanax; Pharmacia & Upjohn, Peapack, NJ) Clonazepam (Klonopin; Roche Laboratories, Inc, Nutley, NJ) Diazepam (Valium; Roche Laboratories, Inc) Lorazepam (Ativan; Wyeth-Ayerst Pharmaceuticals, Philadelphia, PA) Antidepressants Amitriptyline (Elavil; AstraZeneca, Wilmington, DE; and Etrafon; Schering Corp, Kenilworth, NJ) Fluoxetine (Prozac; Dista Products Co, Indianapolis, IN) Nefazodone (Serzone; Bristol-Myers, New York, NY) Nortriptyline (Pamelor; Novartis Pharmaceuticals, East Hanover, NJ) Paroxetine (Paxil; SmithKline Beecham, Philadelphia, PA) Sertraline (Zoloft; Pfizer Inc, New York, NY) Trazodone (Desyrel; Geneva Pharmaceuticals, Broomfield, CO) Venlafaxine (Effexor; Wyeth-Ayerst Pharmaceuticals)
2
14 3 1 5
10 7 2 1 3 1 4 1
bances. In their study of the effectiveness of nortriptyline in tinnitus treatment, Dobie et al16 stated that ‘‘insomnia is a prominent component of distress for tinnitus patients, with and without major depression, and adequate antidepressant therapy usually improves sleep.’’ For some patients, over-the-counter sleep aids—including melatonin17—provide sufficient relief from insomnia. 3) The combination of information gathering, reassurance, and the implementation of effective treatment programs enables many tinnitus patients to improve their coping skills and to develop the ability to divert their attention away from their tinnitus. Patients often require substantial amounts of time after the onset of tinnitus to develop these types of adaptive strategies. Findings from the present study as well as those by Tyler and Baker1 and Scott et al8 indicate that tinnitus severity tends to decrease with increased time from its onset. Although many patients in the present study improved in both sleep disturbance and tinnitus severity, there were still 43 patients who reported on the follow-up questionnaire that they ‘‘often’’ have difficulty sleeping. These patients also reported that their tinnitus seemed louder and more severe than other patients in the study who had less sleep disturbance. In order to reduce the severity of tinnitus for these patients, it is imperative to treat their insomnia. The 43 patients in the ‘‘often’’ sleep-disturbed group were contacted and advised about possible treatments for insomnia. In extreme cases, it might be advisable for a patient to visit a specialized sleep clinic. Stouffer et al18 asked 528 patients to rate different conditions that reduced the severity of their tinnitus. The condition mentioned most often was sleep, by 26% of the respondents. The next 2 conditions mentioned most often were listening to television or radio (by 23% of respondents) and being in a noisy environment (by 19%). The findings of this and the present study underscore the importance of identifying and treating insomnia when it is coincident with tinnitus. Improved sleep patterns can reduce the perceived severity of tinnitus for many patients.
TINNITUS AND INSOMNIA
REFERENCES 1. Tyler RS, Baker LJ: Difficulties experienced by tinnitus sufferers. J Speech Hear Disord 48:150-154, 1983 2. Jakes SC, Hallam RS, Chambers C, et al: A factor analytical study of tinnitus complaint behaviour. Audiology 24:195-206, 1985 3. Axelsson A, Ringdahl A: Tinnitus—a study of its prevalence and characteristics. Br J Audiol 23:53-62, 1989 4. Sanchez L, Stephens D: A tinnitus problem questionnaire in a clinic population. Ear Hear 18:210-217, 1997 5. Hallam RS, Jakes SC, Hinchcliffe R: Cognitive variables in tinnitus annoyance. Br J Clin Psychol 27:213-222, 1988 6. Hallam RS: Correlates of sleep disturbance in chronic distressing tinnitus. Scand Audiology 25:263-266, 1996 7. Meikle MB, Vernon J, Johnson RM: The perceived severity of tinnitus. Otolaryngol Head Neck Surg 92:689696, 1984 8. Scott B, Lindberg P, Melin L, et al: Predictors of tinnitus discomfort, adaptation and subjective loudness. Br J Audiol 24:51-62, 1990 9. Erlandsson SI, Hallberg LRM, Axelsson A: Psychological and audiological correlates of perceived tinnitus severity. Audiology 31:168-179, 1992 10. Alster J, Shemesh Z, Ornan M, et al: Sleep disturbance associated with chronic tinnitus. Biol Psychiatry 34:84-90, 1993
293
11. Vernon J: Assessment of the tinnitus patient, in Hazell JWP (ed): Tinnitus. New York, NY, Churchill Livingstone, 1987, pp 71-95 12. Johnson RM: The masking of tinnitus, in Vernon JA (ed): Tinnitus Treatment and Relief. Englewood Cliffs, NJ, Prentice Hall, 1998, pp 164-186 13. Meikle MB: Methods for evaluation of tinnitus relief procedures, in Aran JM, Dauman R (eds): Tinnitus 91: Proceedings of the Fourth International Tinnitus Seminar. Amsterdam, The Netherlands, Kugler Publications, 1992, pp 555-562 14. Meikle MB, Griest SE, Stewart BJ, et al: Measuring the negative impact of tinnitus: A brief severity index. Abstr Assoc Res Otolaryngology, 1995, p 167 (abstr) 15. Slater R, Terry M: Tinnitus: A Guide for Sufferers and Professionals. London, UK, Croom Helm Ltd 121-131, 1987 16. Dobie RA, Sakai CS, Sullivan MD, et al: Antidepressant treatment of tinnitus patients: Report of a randomized clinical trial and clinical prediction of benefit. Am J Otol 14:18-23, 1993 17. Rosenberg SI, Silverstein H, Rowan PT, et al: Effects of melatonin on tinnitus. Laryngoscope 108:305-310, 1998 18. Stouffer JL, Tyler RS, Kileny PR, et al: Tinnitus as a function of duration and etiology: Counseling implications. Am J Otol 12:188-194, 1991
Tyler and Baker1 asked patients to list the difficulties they experienced as a result of their tinnitus. The most frequently listed difficulty was ‘‘getting to sleep,’’ a complaint reported by 41 (56.9%) of the 72 respondents. Jakes et al2 and Axelsson and Ringdahl3 also reported that insomnia was the problem most frequently mentioned by patients with tinnitus. Sanchez and Stephens4 mailed Tyler and Baker’s1 questionnaire to 436 patients who were scheduled to visit the Tinnitus Clinic of the Welsh Hearing Institute at the University Hospital of Wales in Cardiff, England. Sleep From the Tinnitus Clinic, Oregon Hearing Research Center, Department of Otolaryngology, Oregon Health Sciences University, Portland, OR. Address reprint requests to Robert L. Folmer, PhD, Oregon Hearing Research Center, NRCO4, 3181 SW Sam Jackson Park Rd, Portland, OR 97201-3098. Copyright r 2000 by W.B. Saunders Company 0196-0709/00/2105-0001$10.00/0 doi:10.1053/ajot.2000.9871
difficulty was the second most common complaint, listed by 25% of the respondents. Hearing problems, the most common difficulty, was mentioned by 30% of the patients. Hallam et al5 reported that the 3 main areas of complaint identified by 79 tinnitus patients at a neuro-otology clinic were emotional distress, hearing difficulties, and sleep disturbance. Hallam6 estimated that approximately 50% of tinnitus patients experience disturbances of the normal sleep pattern. In their study of tinnitus severity, Meikle et al7 analyzed responses to questionnaires from more than 1,800 patients who attended the Tinnitus Clinic at Oregon Health Sciences University. There was no correlation between self-rated tinnitus severity and the loudness, type, quality, or pitch of tinnitus sounds heard by patients. However, tinnitus severity ratings were highly correlated with sleep disturbance. Axelsson and Ringdahl,3 Scott et al,8 Erlandsson et al,9 and Alster et al10 also reported that
American Journal of Otolaryngology, Vol 21, No 5 (September-October), 2000: pp 287-293
287
288
tinnitus was more severe in patients who experienced insomnia. It is clear that sleep disturbance is a major problem for many people with tinnitus. The goal of the present study was to investigate the effects of insomnia on tinnitus severity and to examine how this relationship may evolve with the passage of time. Ultimately, we hope that this information will (1) be used for developing and implementing effective treatment programs and (2) contribute to the development and refinement of diagnostic and assessment procedures for tinnitus. METHOD Detailed questionnaires were mailed to patients before their initial appointment at the Oregon Health Sciences University Tinnitus Clinic between 1994 and 1997. These questionnaires requested information about patients’ medical, hearing, and tinnitus histories.11-12 The initial appointment at the clinic had the following format (many of these procedures were described by Johnson12): (1) Patients met with staff members for an in-depth interview and review of their medical, hearing, tinnitus, and psychosocial histories and conditions. Patients received information about possible causes of their tinnitus as well as reassurance and counseling regarding factors that could exacerbate or improve their condition. (2) Audiological evaluations that included puretone air and bone conduction thresholds, speech perception in quiet and noise, maximum comfort level/uncomfortable loudness level, and tympanometry. (3) Tinnitus evaluations that included matching tinnitus to sounds played through headphones, determination of minimum masking levels, and measurements of residual inhibition. (4) Evaluations of acoustic therapies—based on the patient’s audiological evaluations, various devices would be demonstrated. These could include hearing aids, (in-the-ear sound generators), tinnitus instruments (combinations of hearing aids and sound generators), tabletop sound generation machines, masking tapes, or CDs. (5) Review of the results of evaluations, presentation of treatment plan, and other recommendations. Follow-up questionnaires were mailed to 350 patients 1 to 4 years (mean ⫽ 2.30 ⫾ 0.76 yr) after their initial appointment. Figure 1 contains a copy of the follow-up questionnaire. These questions were also asked in the initial questionnaires. Questions 1 through 11 constitute a Tinnitus Severity Index13,14 (TSI) which assesses the negative impacts
FOLMER AND GRIEST
of tinnitus on patients. Numerical responses to questions 1 through 11 were added together to give a total TSI score for each patient. Data relating to patient demographics, audiometric thresholds, reported tinnitus loudness, and reported sleep disturbance were analyzed for patients who returned follow-up questionnaires.
RESULTS One hundred seventy-four patients (130 men, 44 women) returned follow-up questionnaires. This higher percentage of men is consistent with the usual percentage (⬎70%) of men seen in this clinic. Table 1 contains grand averaged pure-tone air conduction thresholds and standard deviations for all 174 patients. This pattern of high-frequency sensorineural hearing loss is typical for our patient population. For the remaining analyses of initial and follow-up questionnaires, patients were divided into 3 groups based on their response to question 12: ‘‘Does your tinnitus interfere with sleep?’’ Table 2 contains the numbers of patients who answered ‘‘no,’’ ‘‘yes, sometimes,’’ or ‘‘yes, often’’ to this question. The net improvement in sleep disturbance from the initial to the follow-up questionnaire was as follows: 11 men and 7 women moved from the ‘‘often’’ group to the ‘‘no’’ group, and 1 woman moved from the ‘‘often’’ group to the ‘‘sometimes’’ group. Comparisons of averaged audiometric thresholds among the ‘‘no,’’ ‘‘sometimes,’’ and ‘‘often’’ groups showed no significant differences on either the initial or follow-up questionnaires; ie, there were no significant differences in hearing loss among groups of tinnitus patients with differing degrees of sleep disturbance. Table 3 contains the mean ages and standard deviations of each group of patients. The age range for patients making their initial visit to the clinic was 17 to 83 years. The age range for patients who returned the follow-up questionnaire was 20 to 85 years. At the time of the patients’ initial appointment, the only significant difference is greater age for those who reported no sleep disturbance than for those who reported that they often have trouble sleeping (P ⫽ .022). There were no significant differences in age among the 3 groups of
TINNITUS AND INSOMNIA
289
Fig 1. Tinnitus severity index questions.
patients who responded to the follow-up questionnaire. Table 4 contains distributions of patients according to the number of years since tinnitus onset at the time of their initial appointment. Greater sleep disturbance is correlated with a higher percentage of patients whose tinnitus began within 2 years of their initial appointment. For example, 33.3% of the patients with no sleep interference had tinnitus that began within 2 years of their initial appointment. This percentage increased to 47.1%
for patients who reported that they sometimes have difficulty sleeping, and it increased to 61.2% for patients who reported that they often experience insomnia. In general, patients with tinnitus that began within 2 years were more likely to experience sleep difficulties than patients who had tinnitus for 3 or more years. Table 5 contains means and standard deviations of reported loudness (on a 1-to-10 scale) of tinnitus for each of the 3 sleep interference groups on both the initial and follow-up ques-
TABLE 1. Grand Averages of Pure-Tone Air Conduction Thresholds of Patients (dB HL) (Hz) Right Ear Left Ear
250
500
1,000
2,000
3,000
4,000
6,000
8,000
14.3 ⫾ 11.2 15.5 ⫾ 14.4
12.9 ⫾ 12.0 14.3 ⫾ 15.4
16.5 ⫾ 14.1 16.5 ⫾ 16.8
21.9 ⫾ 19.7 24.6 ⫾ 21.5
33.1 ⫾ 24.1 36.7 ⫾ 23.9
43.3 ⫾ 25.6 44.8 ⫾ 25.4
46.2 ⫾ 25.0 47.6 ⫾ 24.8
47.9 ⫾ 27.4 50.1 ⫾ 26.5
290
FOLMER AND GRIEST
TABLE 2. Patients’ Responses to ‘‘Does Your Tinnitus
TABLE 4. Years Since Onset of Tinnitus at the Time of
Interfere With Sleep?’’
Initial Appointment vs. Numbers of Patients Reporting Sleep Difficulty Initial
No Sometimes Often Total
Follow-Up
Males
Females
Males
Females
34 52 44 130
8 18 18 44
45 52 33 130
15 19 10 44
tionnaires. Significant differences in reported loudness occurred between the group of patients who often had trouble sleeping and the groups who never or sometimes had sleep disturbance (P ⱕ .0005 for all of these comparisons on both questionnaires). Table 5 also contains means and standard deviations of TSI scores for each of the 3 sleep groups on both questionnaires. One-way analyses of variance indicated that there was a significant difference in TSI scores among the 3 sleep groups on both the initial (F ⫽ 31.0; P ⱕ .0005) and follow-up (F ⫽ 59.5; P ⱕ .0005) questionnaires. Results of multiple comparisons (Scheffe tests) of TSI scores made among the 3 sleep groups are listed in Table 5. In general, TSI scores increased significantly with reported sleep interference on both the initial and follow-up questionnaires. The mean numerical response to almost every TSI question was significantly greater for the ‘‘often’’ group compared with either the ‘‘no’’ or ‘‘sometimes’’ sleep interference groups. The 2 exceptions were ‘‘Does your tinnitus make it harder to interact pleasantly with others?’’ and ‘‘Does your tinnitus interfere with your social activities or other things you do in your leisure time?’’ on the initial questionnaire. There were significant differences in mean responses between the ‘‘no’’ and ‘‘sometimes’’ groups for 5 of the TSI questions (those pertaining to discomfort in a quiet room, feeling TABLE 3. Average Ages of Patients (yrs)
No Sometimes Often Grand Average
Initial
Follow-Up
57.1 ⫾ 11.2 (n ⫽ 42) 54.0 ⫾ 11.0 (n ⫽ 70) 50.7 ⫾ 12.0 (n ⫽ 62) 53.6 ⫾ 11.6
57.7 ⫾ 10.2 (n ⫽ 60) 55.9 ⫾ 12.9 (n ⫽ 71) 53.6 ⫾ 10.8 (n ⫽ 43) 55.9 ⫾ 11.6
No Sometimes Often
⬍1
1-2
3-5
6-10
11-20
⬎20 (yrs)
9 19 23
5 14 15
1 12 6
6 6 4
12 6 8
9 13 6
irritable or nervous, feeling tired or stressed, difficulty relaxing, and usual discomfort experienced) on the initial questionnaire. However, significant differences in responses between these 2 groups of patients were seen for all 11 TSI questions on the follow-up questionnaire. Responses from the ‘‘often’’ sleep interference group were significantly greater than those given by either of the other 2 groups for all 11 TSI questions on the follow-up questionnaire. DISCUSSION Audiometric Thresholds Most of the patients in this study had bilateral high frequency sensorineural hearing loss beginning between 2000 to 3000 Hz. However, pure-tone air conduction thresholds of patients with greater reported sleep interference were not significantly different from thresholds of patients with fewer sleep disturbances. This observation is in contrast to the findings of Alster et al,10 who reported that greater sleep disturbance was correlated with greater hearing loss in their study of 80 tinnitus patients. There are several possible explanations for the differing results of these studies: (1) patients in the study by Alster et al10 were significantly younger (mean age 36 ⫾ 11 yr) than the patients in the present study (mean age 53.6 ⫾ 11.6 yr at the time of their initial appointment); (2) a greater percentage of patients in the study by Alster et al10 were men (95.0% vs 74.7% in the present study); (3) all of the patients in the study by Alster et al10 had been Israeli army personnel, 95% of whom had noise-induced hearing loss (NIHL); (4) the average hearing loss for NIHL patients in the study by Alster et al10 was 46 dB HL in the frequency range between 2 to 8 kHz; the average hearing loss across the same frequency range for patients in the present study
TINNITUS AND INSOMNIA
291
TABLE 5. Means and Standard Deviations of Responses Initial Questionnaire
Reported Loudness of Tinnitus TSI Score Scheffe Comparisons of Reported Loudness Between Groups Pⱕ Scheffe Comparisons of Mean TSI Scores Between Groups Pⱕ
Follow-Up Questionnaire
Group 1
Group 2
Group 3
Group 1
Group 2
Group 3
No (n ⫽ 42)
Sometimes (n ⫽ 70)
Often (n ⫽ 62)
No (n ⫽ 60)
Sometimes (n ⫽ 71)
Often (n ⫽ 43)
5.74 ⫾ 1.89 28.46 ⫾ 8.81
6.23 ⫾ 1.90 33.18 ⫾ 6.60
7.78 ⫾ 1.75 40.09 ⫾ 6.62
5.53 ⫾ 2.26 25.12 ⫾ 7.79
6.17 ⫾ 1.89 31.58 ⫾ 5.94
7.92 ⫾ 1.62 39.93 ⫾ 6.56
1 and 2 .442
1 and 3 .0005
2 and 3 .0005
1 and 2 .184
1 and 3 .0005
2 and 3 .0005
1 and 2 .006
1 and 3 .0005
2 and 3 .0005
1 and 2 .0005
1 and 3 .0005
2 and 3 .0005
was 39.6 dB HL. Any or all of these factors could have contributed to the association between sleep interference and audiometric data observed in each of these studies. Time Since Onset of Tinnitus In the present study, tinnitus that had its onset within 2 years of the patients’ initial appointment was correlated with a greater probability of sleep interference than tinnitus that had been present for 3 or more years (Table 4). Tyler and Baker1 reported that the number of problems experienced by tinnitus patients decreased with increased time since the onset of their tinnitus. Similarly, Scott et al8 reported that their patients’ tolerance to tinnitus increased with time since tinnitus onset. These observations could be part of the reason that patients with recent-onset tinnitus in the present study were more likely to experience sleep interference than patients who had tinnitus for 3 years or more. Increased tolerance to tinnitus over time probably also contributed to the net improvement of sleep patterns experienced by patients from the time of the initial questionnaires to the follow-up questionnaires. Loudness of Tinnitus Patients who often experienced sleep interference in the present study rated their tinnitus as significantly louder (on a 1-to-10 visual scale) than patients who never or sometimes experienced sleep disturbances. This associa-
tion between sleep difficulty and reported tinnitus loudness was also observed by Slater and Terry.15 Meikle et al7 reported that tinnitus severity was not correlated with the matched loudness of the sound. Tinnitus loudness reported on a visual scale might be a better indicator of perceived severity than tinnitus loudness that is matched to a sound presented through headphones. CONCLUSIONS In the present study, greater sleep interference was correlated with greater tinnitus severity. This conclusion is in agreement with the findings of several other studies.3,7-10 Differences in tinnitus severity among the 3 sleep interference groups were more pronounced on the follow-up questionnaire than on the initial questionnaire. A possible explanation for this is that the passage of time—an average of 2.3 years—from the initial to the follow-up questionnaire reduced the influence of earlier tinnitus onset observed on the initial questionnaire. By the time that they completed the follow-up questionnaire, all 174 patients in the present study had experienced tinnitus for more than 1 year, and the average time since the onset of their tinnitus had increased by 2.3 years. According to their responses on the initial and follow-up questionnaires, patients in the present study reported an overall improvement in both sleep interference and tinnitus severity. There were several factors that contributed to these improvements:
292
FOLMER AND GRIEST
1) Patients received information about tinnitus, reassurance and counseling, audiometric and tinnitus evaluations, and treatment recommendations during their initial appointment. 2) Patients implemented recommended treatments including masking tapes or CDs; bedside sound generating machines; in-the-ear sound generators, hearing aids, or combination instruments (combinations of hearing aids and sound generators); relaxation and stress management therapies; psychological counseling; changes in diet (eg, reducing intake of caffeine or alcohol); protecting their ears from excessively loud sounds; massage, exercise, and biofeedback; and medications to improve sleep. Table 6 lists the medications that were taken by patients in the present study for insomnia, depression, and anxiety. In addition to any anxiolytic or antidepressant actions they might have, all of these medications can produce drowsiness and reduce sleep disturTABLE 6. Medications Used by Patients in the Present Study No. of Patients Using Hypnotics Zolpidem (Ambien; GD Searle & Co, Chicago, IL) Anxiolytics/Sedatives Alprazolam (Xanax; Pharmacia & Upjohn, Peapack, NJ) Clonazepam (Klonopin; Roche Laboratories, Inc, Nutley, NJ) Diazepam (Valium; Roche Laboratories, Inc) Lorazepam (Ativan; Wyeth-Ayerst Pharmaceuticals, Philadelphia, PA) Antidepressants Amitriptyline (Elavil; AstraZeneca, Wilmington, DE; and Etrafon; Schering Corp, Kenilworth, NJ) Fluoxetine (Prozac; Dista Products Co, Indianapolis, IN) Nefazodone (Serzone; Bristol-Myers, New York, NY) Nortriptyline (Pamelor; Novartis Pharmaceuticals, East Hanover, NJ) Paroxetine (Paxil; SmithKline Beecham, Philadelphia, PA) Sertraline (Zoloft; Pfizer Inc, New York, NY) Trazodone (Desyrel; Geneva Pharmaceuticals, Broomfield, CO) Venlafaxine (Effexor; Wyeth-Ayerst Pharmaceuticals)
2
14 3 1 5
10 7 2 1 3 1 4 1
bances. In their study of the effectiveness of nortriptyline in tinnitus treatment, Dobie et al16 stated that ‘‘insomnia is a prominent component of distress for tinnitus patients, with and without major depression, and adequate antidepressant therapy usually improves sleep.’’ For some patients, over-the-counter sleep aids—including melatonin17—provide sufficient relief from insomnia. 3) The combination of information gathering, reassurance, and the implementation of effective treatment programs enables many tinnitus patients to improve their coping skills and to develop the ability to divert their attention away from their tinnitus. Patients often require substantial amounts of time after the onset of tinnitus to develop these types of adaptive strategies. Findings from the present study as well as those by Tyler and Baker1 and Scott et al8 indicate that tinnitus severity tends to decrease with increased time from its onset. Although many patients in the present study improved in both sleep disturbance and tinnitus severity, there were still 43 patients who reported on the follow-up questionnaire that they ‘‘often’’ have difficulty sleeping. These patients also reported that their tinnitus seemed louder and more severe than other patients in the study who had less sleep disturbance. In order to reduce the severity of tinnitus for these patients, it is imperative to treat their insomnia. The 43 patients in the ‘‘often’’ sleep-disturbed group were contacted and advised about possible treatments for insomnia. In extreme cases, it might be advisable for a patient to visit a specialized sleep clinic. Stouffer et al18 asked 528 patients to rate different conditions that reduced the severity of their tinnitus. The condition mentioned most often was sleep, by 26% of the respondents. The next 2 conditions mentioned most often were listening to television or radio (by 23% of respondents) and being in a noisy environment (by 19%). The findings of this and the present study underscore the importance of identifying and treating insomnia when it is coincident with tinnitus. Improved sleep patterns can reduce the perceived severity of tinnitus for many patients.
TINNITUS AND INSOMNIA
REFERENCES 1. Tyler RS, Baker LJ: Difficulties experienced by tinnitus sufferers. J Speech Hear Disord 48:150-154, 1983 2. Jakes SC, Hallam RS, Chambers C, et al: A factor analytical study of tinnitus complaint behaviour. Audiology 24:195-206, 1985 3. Axelsson A, Ringdahl A: Tinnitus—a study of its prevalence and characteristics. Br J Audiol 23:53-62, 1989 4. Sanchez L, Stephens D: A tinnitus problem questionnaire in a clinic population. Ear Hear 18:210-217, 1997 5. Hallam RS, Jakes SC, Hinchcliffe R: Cognitive variables in tinnitus annoyance. Br J Clin Psychol 27:213-222, 1988 6. Hallam RS: Correlates of sleep disturbance in chronic distressing tinnitus. Scand Audiology 25:263-266, 1996 7. Meikle MB, Vernon J, Johnson RM: The perceived severity of tinnitus. Otolaryngol Head Neck Surg 92:689696, 1984 8. Scott B, Lindberg P, Melin L, et al: Predictors of tinnitus discomfort, adaptation and subjective loudness. Br J Audiol 24:51-62, 1990 9. Erlandsson SI, Hallberg LRM, Axelsson A: Psychological and audiological correlates of perceived tinnitus severity. Audiology 31:168-179, 1992 10. Alster J, Shemesh Z, Ornan M, et al: Sleep disturbance associated with chronic tinnitus. Biol Psychiatry 34:84-90, 1993
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11. Vernon J: Assessment of the tinnitus patient, in Hazell JWP (ed): Tinnitus. New York, NY, Churchill Livingstone, 1987, pp 71-95 12. Johnson RM: The masking of tinnitus, in Vernon JA (ed): Tinnitus Treatment and Relief. Englewood Cliffs, NJ, Prentice Hall, 1998, pp 164-186 13. Meikle MB: Methods for evaluation of tinnitus relief procedures, in Aran JM, Dauman R (eds): Tinnitus 91: Proceedings of the Fourth International Tinnitus Seminar. Amsterdam, The Netherlands, Kugler Publications, 1992, pp 555-562 14. Meikle MB, Griest SE, Stewart BJ, et al: Measuring the negative impact of tinnitus: A brief severity index. Abstr Assoc Res Otolaryngology, 1995, p 167 (abstr) 15. Slater R, Terry M: Tinnitus: A Guide for Sufferers and Professionals. London, UK, Croom Helm Ltd 121-131, 1987 16. Dobie RA, Sakai CS, Sullivan MD, et al: Antidepressant treatment of tinnitus patients: Report of a randomized clinical trial and clinical prediction of benefit. Am J Otol 14:18-23, 1993 17. Rosenberg SI, Silverstein H, Rowan PT, et al: Effects of melatonin on tinnitus. Laryngoscope 108:305-310, 1998 18. Stouffer JL, Tyler RS, Kileny PR, et al: Tinnitus as a function of duration and etiology: Counseling implications. Am J Otol 12:188-194, 1991