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Tinnitus severity, depression, and the big five personality traits
B. Langguth, G. Hajak, T. Kleinjung, A. Cacace & A.R. Møller (Eds.) Progress in Brain Research, Vol. 166 ISSN 0079-6123 Copyright r 2007 Elsevier B.V. All rights reserved
CHAPTER 20
Tinnitus severity, depression, and the big five personality traits B. Langguth1,, T. Kleinjung2, B. Fischer2, G. Hajak1, P. Eichhammer1 and P.G. Sand1 2
1 Department of Psychiatry, University of Regensburg, Regensburg, Germany Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany
Abstract: A growing number of self-report measures for the evaluation of tinnitus severity has become available to research and clinical practice. This has led to an increased awareness of depression and personality as predictors of tinnitus severity in addition to loudness and other psychoacoustic measures. However, the net impact of personality dimensions on tinnitus ratings has not been investigated when the effect of depressed mood is controlled. In the present study, we demonstrate the role of the big five personality traits, ‘Neuroticism’, ‘Extraversion’, ‘Openness’, ‘Agreeableness’, and ‘Conscientiousness’, in affecting scores on two standard instruments for grading tinnitus-related complaints, the tinnitus handicap inventory (THI), and the tinnitus questionnaire (TQ). When 72 individuals with chronic tinnitus were examined, ‘Agreeableness’ negatively correlated with THI scores ( p ¼ .003), whereas the anxiety trait ‘Neuroticism’ correlated both with depressive symptomatology ( po.001) and TQ scores ( p ¼ .028), but not with THI ratings (n.s.). In addition to confirming the established roles of trait anxiety and depression, low ‘Agreeableness’ was thus identified as a novel predictor of tinnitus severity on the THI. Keywords: tinnitus; big five personality traits; predictors; affective comorbidity; coping perception and report of distress associated with tinnitus. Close collaborations between audiologists and mental health professionals have been established in many specialized clinics to meet the specific challenges posed by these interactions (Reynolds et al., 2004). Among the personality traits that have been identified in the past as predictors of subjective tinnitus severity counts self-reported anxiety (Halford and Anderson, 1991; Langenbach et al., 2005). Measures of anxiety sensitivity, or of excessive pre-occupation with somatic symptoms are often used in combination with tools addressing depression to adequately assess the severity of tinnitus at initial screenings, and to evaluate treatment outcome (Reynolds et al., 2004). Except for
Introduction The interplay of personality traits, depressed mood, and tinnitus severity is highly relevant to diagnosis and prognosis in tinnitus-related handicap (Russo et al., 1994). Depression often occurs together with tinnitus (Harrop-Griffiths et al., 1987) and frequently augments functional disability in individuals with tinnitus (Sullivan et al., 1993). In the light of strong placebo effects in tinnitus (Dobie et al., 1993), psychological factors play a further modulatory role in shaping the Corresponding author. Tel.: +49 941 941 2099; Fax: +49 941 941 2025; E-mail: [email protected] DOI: 10.1016/S0079-6123(07)66020-8
221
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the contributory roles of depression and anxiety, however, little is known about personality-specific risk factors. Likewise, little is known about the relationship between temperament, self-reported depression and other forms of tinnitus-related handicap (Zachariae et al., 2000). There is preliminary evidence that the respective measures are not independent of each other and that symptom severity scales may give skewed results when personality traits and affective states are nor controlled for (Langenbach et al., 2005). In order to further improve our understanding of factors that may augment, or reduce, the morbidity associated with chronic tinnitus we therefore compared the outcome of two widely used tinnitus severity scales in relation to the severity of depression and individuals’ temperament. To this avail, we studied 72 individuals suffering from chronic tinnitus who were administered the tinnitus handicap inventory (THI; Newman et al., 1998; Kleinjung et al., 2007), the tinnitus questionnaire (TQ; Hallam et al., 1988; Goebel and Hiller, 1994), the Beck depression inventory (BDI; Beck et al., 1988), and the NEO-five factor inventory (NEO-FFI; Costa and McCrae, 1985). Partial correlations were computed of NEO-FFI subscales with the BDI, TQs, age, and gender.
Methods One hundred patients who had presented consecutively to the university tinnitus clinic in the months preceding February 2005 were enrolled in the study. All had reported tinnitus as their primary complaint at the time of their audiologic examination, and had undergone a neurootological examination including otoscopy, recording of the acoustic middle ear reflexes, tympanometry (middle ear pressure measurements), pure tone audiometry, and tinnitus pitch and loudness matching. Questionnaires were administered by mail with a stamped return envelope and an accompanying letter providing instructions on how to fill out the NEO-FFI, BDI, THI, and TQ. Where required, demographic data (age, sex, and history length) and descriptive data about the tinnitus were reconfirmed by telephone interviews
to supplement the subjects’ medical records. Seventy-two of the 100 individuals who were enrolled in the study returned fully completed sets of questionnaires. Of these, 50 participants were men (mean age 49.3713.0 years, range: 19–75) and 22 were women (mean age 49.4713.1 years, range: 23–73). All participants complained of chronic tinnitus. The age at onset of tinnitus was 43.1712.6 years (range: 17.5–66.5) in men, and 43.2713.1 years (range: 21–65) in women. All participants had experienced tinnitus for at least 6 months; 25 individuals (34.7%) reported tinnitus persisting for more than 5 years. Descriptive statistics, normality tests, and partial correlations were calculated using STATA for Macintosh V8.0 (Stata Corporation, College Station, TX, USA). Means are given with the respective standard deviation. The significance level was set at p ¼ .05.
Results Table 1 shows the total scores on the THI and TQ, together with results of distribution analyses. Both measures of severity followed a Gaussian distribution ( p4.22). Using the consensus grading scheme of tinnitus severity from ‘slight’ to ‘catastrophic’ on the THI (McCombe et al., 2001), 13 participants (18.1%) reported grade I (slight) tinnitus, 1 individual only displayed symptoms on the TQ, 17 patients (23.0%) had grade II (mild), 22 participants (30.1%) scored as grade III (moderate) sufferers, 17 (23.6%) reported grade IV Table 1. Mean scores 7 S.D. and Shapiro–Wilk normality test results for measures of five personality traits (NEO-FFI), depressive symptomatology (BDI), and tinnitus severity (THI, TQ)
Neuroticism Extraversion Openness Agreeableness Conscientiousness BDI THI TQ
Mean
z
p
1.8070.68 2.1370.57 2.2570.43 2.5070.38 2.8970.50 11.0079.48 40.30724.11 43.32720.15
0.11 0.02 1.10 0.84 0.72 3.70 0.75 0.75
0.46 0.49 0.86 0.80 0.76 o0.01 0.23 0.23
223
(severe) handicap, and 3 patients (4.2%) scored as grade V. With respect to depression, 20.8% of subjects exhibited moderate to severe symptoms (defined as a score 419 on the BDI scale, Beck et al., 1988), and 34.7% presented with mild depressive symptoms (defined as a score of 10–18). Distribution of BDI scores deviated from normality ( po.01, see Table 1 for mean values and Shapiro–Wilk statistics). As regards personality dimensions, participants in the study scored highest on ‘Conscientiousness’ (2.8970.50), and lowest on ‘Neuroticism’ (1.8070.68). All NEO-FFI scores displayed a normal distribution (Table 1). Correlation analysis revealed that low ‘Agreeabless’ predicted high THI scores ( p ¼ .003) whereas high ‘Neuroticism’ predicted high TQ scores ( p ¼ .028, Table 2). All partial correlations are displayed in Table 2.
Discussion This is the first study to identify low ‘Agreeableness’ as a personality dimension highly correlated with tinnitus severity. Individuals who score low on ‘Agreeableness’ are thought to be highly
competitive, self-centered, and more susceptible to anger (Meier and Robinson, 2004). It is conceivable that such individuals experience more discomfort from tinnitus compared to others, owing to a perceived inability to meet their own expectations and the levels of performance that they are used to achieve in everyday challenges. This may result in frustration, feelings of tenseness and irritability (Sourgen and Ross, 1998), and may increase the handicap from tinnitus. If a causative relationship between low ‘Agreeableness’ and tinnitus severity can be confirmed, predictors of tinnitus severity may overlap with personality profiles of individuals who carry an increased risk of coronary heart disease. It has been noted that cardiovascular complaints are frequent in individuals with tinnitus (Hiller et al., 1997), and behavioral risk factors for coronary diseases have been suggested to promote chronic tinnitus (Stobik et al., 2005). When severity was assessed by the TQ, ‘Neuroticism’ was identified as the only significant personality correlate ( p ¼ .028, Table 2). Individuals who score high on ‘Neuroticism’ tend to experience more anxiety, fear, sadness, embarrassment, and guilt. There is consensus that anxiety is
Table 2. Partial correlations between scales and demographic variables in subjects with chronic tinnitus (N ¼ 72) N Neuroticism (N) Extraversion (E) Openness (O) Agreeableness (A)
E
O
A
C
BDI
Sex
Age
THI
TQ
.353 [.004]
.078 [.545] .080 [.529]
.112 [.378] .065 [.609] .192 [.129]
.130 [.305] .175 [.167] .104 [.414] .293 [.019]
.472 [.000] .089 [.483] .003 [.981] .035 [.782] .104 [.414]
.252 [.045] .036 [.779] .029 [.823] .156 [.219] .037 [.772] .069 [.589]
.282 [.024] .351 [.004] .047 [.715] .003 [.979] .075 [.554] .045 [.727] .063 [.624]
.017 [.892] .054 [.671] .167 [.188] .367 [.003] .222 [.078] .248 [.048] .052 [.686] .186 [.142]
.276 [.028] .106 [.404] .066 [.607] .197 [.119] .087 [.496] .057 [.655] .106 [.406] .357 [.004] .560 [.000]
Conscientiousness (C) BDI Sex Age THI TQ Note: Significant correlations are printed in bold, p values are given in square brackets.
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prevalent in subjects with tinnitus when measured as a state (Reynolds et al., 2004) or, as a trait (Hiller and Goebel, 2004). However, studies using more than one index of anxiety suggest correlations with traits are weaker than those with anxiety states (Andersson et al., 2003). This could explain why no significant correlation of ‘Neuroticism’ was seen with the THI score or, with TQ subscales (data not shown). Alternatively, the TQ and THI may differ in their sensitivity to different facets of trait anxiety as have been proposed by Endler and Kocovski (2001). The present study is also the first systematic study of personality traits in subjects with tinnitus using the NEO-FFI. Previously, investigators have employed Cloninger’s tridimensional personality questionnaire (TPQ) (Russo et al., 1994), the Freiburger personality inventory (FPI-R), the symptom checklist-90-revised (SCL-90-R) (Sullivan et al., 1993; Langenbach et al., 2005), the Minnesota multiphasic personality inventory (MMPI) (Collet et al., 1990), or the Eysenck personality inventory (EPQ) (Zachariae et al., 2000). In contrast to the MMPI and the EPQ, the NEO-FFI has no scales to control for response biases such as social desirability or faking bad. Data obtained with the MMPI, however, argue against intentional bias in populations affected by tinnitus (Bayar et al., 2002; Marciano et al., 2003). As for the strong correlations between the trait ‘Neuroticism’, female gender (p ¼ .045), and age (negative correlation, p ¼ .024), others have shown that a decrease in ‘Neuroticism’ with age, especially in women, occurs independently of tinnitus when large cohorts are studied from the general population (Srivastava et al., 2003). A significant correlation of tinnitus severity was equally noted with depression. Depression is common in individuals with chronic tinnitus (Zoger et al., 2001), which may indicate that individuals with tinnitus have poor compensation strategies, or a predisposition for both conditions. Negative effects of depression on coping behaviors may manifest as nonhabituation to tinnitus symptoms (Reynolds et al., 2004), and a reduced drive to seek medical attention. At the same time, depression occurring together with tinnitus may render some interventions for tinnitus less effective, e.g. the
practice of cognitive behavioral therapy. A major emerging risk factor for depressive comorbidity is internal focus (Newman et al., 1997). Hallam et al. (1988) first postulated that attentional processes akin to obsessional ruminations play a key role in modulating the perceived handicap from tinnitus. Others have confirmed the joint contribution of depression, somatic perception, and temperament to the psychological strain defining the handicap from tinnitus (Perrig-Chiello and Gusset, 1996). Conclusions Significant correlations have emerged among the severity of tinnitus, depression, and two dimensions of personality. Tinnitus severity was predicted by low ‘Agreeableness’ and high ‘Neuroticism’, but the degree of correlation depended on which measure of severity was used. It remains to be seen whether the unhappy triad ‘‘depression, anxiety/‘Neuroticism’ and irritability/low ‘Agreeableness’’’ is an indicator of somatic comorbidity that may warrant adaptations of interventional techniques in individuals with chronic tinnitus. Abbreviations BDI NEO FFI THI TQ
Beck depression inventory NEO-five factor inventory tinnitus handicap inventory tinnitus questionnaire
Acknowledgments The authors wish to thank Sandra Pfluegl and Helene Niebling for assistance with data collection. The study was supported by a grant from the Tinnitus Research Initiative. References Andersson, G., Kaldo-Sandstrom, V., Strom, L. and Stromgren, T. (2003) Internet administration of the hospital anxiety and depression scale in a sample of tinnitus patients. J. Psychosom. Res., 55: 259–262.
225 Bayar, N., Oguzturk, O. and Koc, C. (2002) Minnesota multiphasic personality inventory profile of patients with subjective tinnitus. J. Otolaryngol., 31: 317–322. Beck, A.T., Steer, R.A. and Garbin, M.G. (1988) Psychometric properties of the Beck depression inventory: twenty-five years of evaluation. Clin. Psychol. Rev., 8: 77. Collet, L., Moussu, M.F., Disant, F., Ahami, T. and Morgon, A. (1990) Minnesota multiphasic personality inventory in tinnitus disorders. Audiology, 29: 101–106. Costa, P.T. and McCrae, R.R. (1985) The NEO Personality Inventory. Manual Form S and Form R. Psychological Assessment Resources, Odessa, FL. Dobie, R.A., Sakai, C.S., Sullivan, M.D., Katon, W.J. and Russo, J. (1993) Antidepressant treatment of tinnitus patients: report of a randomized clinical trial and clinical prediction of benefit. Am. J. Otol., 14: 18–23. Endler, N.S. and Kocovski, N.L. (2001) State and trait anxiety revisited. J. Anxiety. Disord., 15: 231–245. Goebel, G. and Hiller, W. (1994) The tinnitus questionnaire. A standard instrument for grading the degree of tinnitus. Results of a multicenter study with the tinnitus questionnaire. HNO, 42: 166–172. Halford, J.B. and Anderson, S.D. (1991) Tinnitus severity measured by a subjective scale, audiometry and clinical judgement. J. Laryngol. Otol., 105: 89–93. Hallam, R.S., Jakes, S.C. and Hinchcliffe, R. (1988) Cognitive variables in tinnitus annoyance. Br. J. Clin. Psychol., 27(Pt 3): 213–222. Harrop-Griffiths, J., Katon, W., Dobie, R., Sakai, C. and Russo, J. (1987) Chronic tinnitus: association with psychiatric diagnoses. J. Psychosom. Res., 31: 613–621. Hiller, W. and Goebel, G. (2004) Rapid assessment of tinnitusrelated psychological distress using the mini-TQ. Int. J. Audiol., 43: 600–604. Hiller, W., Janca, A. and Burke, K.C. (1997) Association between tinnitus and somatoform disorders. J. Psychosom. Res., 43: 613–624. Kleinjung, T., Fischer, B., Langguth, B., Sand, P.G., Hajak, G., Dvorakova, J. and Eichhammer, P. (2007) Validation of the German-version tinnitus handicap inventory (THI). Psychiatr. Prax., 34: 140–142. Langenbach, M., Olderog, M., Michel, O., Albus, C. and Kohle, K. (2005) Psychosocial and personality predictors of tinnitus-related distress. Gen. Hosp. Psychiatry, 27: 73–77. Marciano, E., Carrabba, L., Giannini, P., Sementina, C., Verde, P., Bruno, C., Di, P.G. and Ponsillo, N.G. (2003) Psychiatric comorbidity in a population of outpatients affected by tinnitus. Int. J. Audiol., 42: 4–9.
McCombe, A., Baguley, D., Coles, R., McKenna, L., McKinney, C. and Windle-Taylor, P. (2001) Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999. Clin. Otolaryngol., 26: 388–393. Meier, B.P. and Robinson, M.D. (2004) Does quick to blame mean quick to anger? The role of agreeableness in dissociating blame and anger. Pers. Soc. Psychol. Bull., 30: 856–867. Newman, C.W., Sandridge, S.A. and Jacobson, G.P. (1998) Psychometric adequacy of the tinnitus handicap inventory (THI) for evaluating treatment outcome. J. Am. Acad. Audiol., 9: 153–160. Newman, C.W., Wharton, J.A. and Jacobson, G.P. (1997) Self-focused and somatic attention in patients with tinnitus. J. Am. Acad. Audiol., 8: 143–149. Perrig-Chiello, P. and Gusset, S. (1996) Differential aspects of subjective burden of tinnitus aurium. Psychother. Psychosom. Med. Psychol., 46: 139–146. Reynolds, P., Gardner, D. and Lee, R. (2004) Tinnitus and psychological morbidity: a cross-sectional study to investigate psychological morbidity in tinnitus patients and its relationship with severity of symptoms and illness perceptions. Clin. Otolaryngol. Allied Sci., 29: 628–634. Russo, J., Katon, W., Sullivan, M., Clark, M. and Buchwald, D. (1994) Severity of somatization and its relationship to psychiatric disorders and personality. Psychosomatics, 35: 546–556. Sourgen, P.M. and Ross, E. (1998) Perceptions of tinnitus in a group of senior citizens. S. Afr. J. Commun. Disord., 45: 61–75. Srivastava, S., John, O.P., Gosling, S.D. and Potter, J. (2003) Development of personality in early and middle adulthood: set like plaster or persistent change? J. Pers. Soc. Psychol., 84: 1041–1053. Stobik, C., Weber, R.K., Munte, T.F., Walter, M. and Frommer, J. (2005) Evidence of psychosomatic influences in compensated and decompensated tinnitus. Int. J. Audiol., 44: 370–378. Sullivan, M., Katon, W., Russo, J., Dobie, R. and Sakai, C. (1993) A randomized trial of nortriptyline for severe chronic tinnitus. Effects on depression, disability, and tinnitus symptoms. Arch. Intern. Med., 153: 2251–2259. Zachariae, R., Mirz, F., Johansen, L.V., Andersen, S.E., Bjerring, P. and Pedersen, C.B. (2000) Reliability and validity of a Danish adaptation of the tinnitus handicap inventory. Scand. Audiol., 29: 37–43. Zoger, S., Svedlund, J. and Holgers, K.M. (2001) Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic. Audiology, 40: 133–140.
CHAPTER 20
Tinnitus severity, depression, and the big five personality traits B. Langguth1,, T. Kleinjung2, B. Fischer2, G. Hajak1, P. Eichhammer1 and P.G. Sand1 2
1 Department of Psychiatry, University of Regensburg, Regensburg, Germany Department of Otorhinolaryngology, University of Regensburg, Regensburg, Germany
Abstract: A growing number of self-report measures for the evaluation of tinnitus severity has become available to research and clinical practice. This has led to an increased awareness of depression and personality as predictors of tinnitus severity in addition to loudness and other psychoacoustic measures. However, the net impact of personality dimensions on tinnitus ratings has not been investigated when the effect of depressed mood is controlled. In the present study, we demonstrate the role of the big five personality traits, ‘Neuroticism’, ‘Extraversion’, ‘Openness’, ‘Agreeableness’, and ‘Conscientiousness’, in affecting scores on two standard instruments for grading tinnitus-related complaints, the tinnitus handicap inventory (THI), and the tinnitus questionnaire (TQ). When 72 individuals with chronic tinnitus were examined, ‘Agreeableness’ negatively correlated with THI scores ( p ¼ .003), whereas the anxiety trait ‘Neuroticism’ correlated both with depressive symptomatology ( po.001) and TQ scores ( p ¼ .028), but not with THI ratings (n.s.). In addition to confirming the established roles of trait anxiety and depression, low ‘Agreeableness’ was thus identified as a novel predictor of tinnitus severity on the THI. Keywords: tinnitus; big five personality traits; predictors; affective comorbidity; coping perception and report of distress associated with tinnitus. Close collaborations between audiologists and mental health professionals have been established in many specialized clinics to meet the specific challenges posed by these interactions (Reynolds et al., 2004). Among the personality traits that have been identified in the past as predictors of subjective tinnitus severity counts self-reported anxiety (Halford and Anderson, 1991; Langenbach et al., 2005). Measures of anxiety sensitivity, or of excessive pre-occupation with somatic symptoms are often used in combination with tools addressing depression to adequately assess the severity of tinnitus at initial screenings, and to evaluate treatment outcome (Reynolds et al., 2004). Except for
Introduction The interplay of personality traits, depressed mood, and tinnitus severity is highly relevant to diagnosis and prognosis in tinnitus-related handicap (Russo et al., 1994). Depression often occurs together with tinnitus (Harrop-Griffiths et al., 1987) and frequently augments functional disability in individuals with tinnitus (Sullivan et al., 1993). In the light of strong placebo effects in tinnitus (Dobie et al., 1993), psychological factors play a further modulatory role in shaping the Corresponding author. Tel.: +49 941 941 2099; Fax: +49 941 941 2025; E-mail: [email protected] DOI: 10.1016/S0079-6123(07)66020-8
221
222
the contributory roles of depression and anxiety, however, little is known about personality-specific risk factors. Likewise, little is known about the relationship between temperament, self-reported depression and other forms of tinnitus-related handicap (Zachariae et al., 2000). There is preliminary evidence that the respective measures are not independent of each other and that symptom severity scales may give skewed results when personality traits and affective states are nor controlled for (Langenbach et al., 2005). In order to further improve our understanding of factors that may augment, or reduce, the morbidity associated with chronic tinnitus we therefore compared the outcome of two widely used tinnitus severity scales in relation to the severity of depression and individuals’ temperament. To this avail, we studied 72 individuals suffering from chronic tinnitus who were administered the tinnitus handicap inventory (THI; Newman et al., 1998; Kleinjung et al., 2007), the tinnitus questionnaire (TQ; Hallam et al., 1988; Goebel and Hiller, 1994), the Beck depression inventory (BDI; Beck et al., 1988), and the NEO-five factor inventory (NEO-FFI; Costa and McCrae, 1985). Partial correlations were computed of NEO-FFI subscales with the BDI, TQs, age, and gender.
Methods One hundred patients who had presented consecutively to the university tinnitus clinic in the months preceding February 2005 were enrolled in the study. All had reported tinnitus as their primary complaint at the time of their audiologic examination, and had undergone a neurootological examination including otoscopy, recording of the acoustic middle ear reflexes, tympanometry (middle ear pressure measurements), pure tone audiometry, and tinnitus pitch and loudness matching. Questionnaires were administered by mail with a stamped return envelope and an accompanying letter providing instructions on how to fill out the NEO-FFI, BDI, THI, and TQ. Where required, demographic data (age, sex, and history length) and descriptive data about the tinnitus were reconfirmed by telephone interviews
to supplement the subjects’ medical records. Seventy-two of the 100 individuals who were enrolled in the study returned fully completed sets of questionnaires. Of these, 50 participants were men (mean age 49.3713.0 years, range: 19–75) and 22 were women (mean age 49.4713.1 years, range: 23–73). All participants complained of chronic tinnitus. The age at onset of tinnitus was 43.1712.6 years (range: 17.5–66.5) in men, and 43.2713.1 years (range: 21–65) in women. All participants had experienced tinnitus for at least 6 months; 25 individuals (34.7%) reported tinnitus persisting for more than 5 years. Descriptive statistics, normality tests, and partial correlations were calculated using STATA for Macintosh V8.0 (Stata Corporation, College Station, TX, USA). Means are given with the respective standard deviation. The significance level was set at p ¼ .05.
Results Table 1 shows the total scores on the THI and TQ, together with results of distribution analyses. Both measures of severity followed a Gaussian distribution ( p4.22). Using the consensus grading scheme of tinnitus severity from ‘slight’ to ‘catastrophic’ on the THI (McCombe et al., 2001), 13 participants (18.1%) reported grade I (slight) tinnitus, 1 individual only displayed symptoms on the TQ, 17 patients (23.0%) had grade II (mild), 22 participants (30.1%) scored as grade III (moderate) sufferers, 17 (23.6%) reported grade IV Table 1. Mean scores 7 S.D. and Shapiro–Wilk normality test results for measures of five personality traits (NEO-FFI), depressive symptomatology (BDI), and tinnitus severity (THI, TQ)
Neuroticism Extraversion Openness Agreeableness Conscientiousness BDI THI TQ
Mean
z
p
1.8070.68 2.1370.57 2.2570.43 2.5070.38 2.8970.50 11.0079.48 40.30724.11 43.32720.15
0.11 0.02 1.10 0.84 0.72 3.70 0.75 0.75
0.46 0.49 0.86 0.80 0.76 o0.01 0.23 0.23
223
(severe) handicap, and 3 patients (4.2%) scored as grade V. With respect to depression, 20.8% of subjects exhibited moderate to severe symptoms (defined as a score 419 on the BDI scale, Beck et al., 1988), and 34.7% presented with mild depressive symptoms (defined as a score of 10–18). Distribution of BDI scores deviated from normality ( po.01, see Table 1 for mean values and Shapiro–Wilk statistics). As regards personality dimensions, participants in the study scored highest on ‘Conscientiousness’ (2.8970.50), and lowest on ‘Neuroticism’ (1.8070.68). All NEO-FFI scores displayed a normal distribution (Table 1). Correlation analysis revealed that low ‘Agreeabless’ predicted high THI scores ( p ¼ .003) whereas high ‘Neuroticism’ predicted high TQ scores ( p ¼ .028, Table 2). All partial correlations are displayed in Table 2.
Discussion This is the first study to identify low ‘Agreeableness’ as a personality dimension highly correlated with tinnitus severity. Individuals who score low on ‘Agreeableness’ are thought to be highly
competitive, self-centered, and more susceptible to anger (Meier and Robinson, 2004). It is conceivable that such individuals experience more discomfort from tinnitus compared to others, owing to a perceived inability to meet their own expectations and the levels of performance that they are used to achieve in everyday challenges. This may result in frustration, feelings of tenseness and irritability (Sourgen and Ross, 1998), and may increase the handicap from tinnitus. If a causative relationship between low ‘Agreeableness’ and tinnitus severity can be confirmed, predictors of tinnitus severity may overlap with personality profiles of individuals who carry an increased risk of coronary heart disease. It has been noted that cardiovascular complaints are frequent in individuals with tinnitus (Hiller et al., 1997), and behavioral risk factors for coronary diseases have been suggested to promote chronic tinnitus (Stobik et al., 2005). When severity was assessed by the TQ, ‘Neuroticism’ was identified as the only significant personality correlate ( p ¼ .028, Table 2). Individuals who score high on ‘Neuroticism’ tend to experience more anxiety, fear, sadness, embarrassment, and guilt. There is consensus that anxiety is
Table 2. Partial correlations between scales and demographic variables in subjects with chronic tinnitus (N ¼ 72) N Neuroticism (N) Extraversion (E) Openness (O) Agreeableness (A)
E
O
A
C
BDI
Sex
Age
THI
TQ
.353 [.004]
.078 [.545] .080 [.529]
.112 [.378] .065 [.609] .192 [.129]
.130 [.305] .175 [.167] .104 [.414] .293 [.019]
.472 [.000] .089 [.483] .003 [.981] .035 [.782] .104 [.414]
.252 [.045] .036 [.779] .029 [.823] .156 [.219] .037 [.772] .069 [.589]
.282 [.024] .351 [.004] .047 [.715] .003 [.979] .075 [.554] .045 [.727] .063 [.624]
.017 [.892] .054 [.671] .167 [.188] .367 [.003] .222 [.078] .248 [.048] .052 [.686] .186 [.142]
.276 [.028] .106 [.404] .066 [.607] .197 [.119] .087 [.496] .057 [.655] .106 [.406] .357 [.004] .560 [.000]
Conscientiousness (C) BDI Sex Age THI TQ Note: Significant correlations are printed in bold, p values are given in square brackets.
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prevalent in subjects with tinnitus when measured as a state (Reynolds et al., 2004) or, as a trait (Hiller and Goebel, 2004). However, studies using more than one index of anxiety suggest correlations with traits are weaker than those with anxiety states (Andersson et al., 2003). This could explain why no significant correlation of ‘Neuroticism’ was seen with the THI score or, with TQ subscales (data not shown). Alternatively, the TQ and THI may differ in their sensitivity to different facets of trait anxiety as have been proposed by Endler and Kocovski (2001). The present study is also the first systematic study of personality traits in subjects with tinnitus using the NEO-FFI. Previously, investigators have employed Cloninger’s tridimensional personality questionnaire (TPQ) (Russo et al., 1994), the Freiburger personality inventory (FPI-R), the symptom checklist-90-revised (SCL-90-R) (Sullivan et al., 1993; Langenbach et al., 2005), the Minnesota multiphasic personality inventory (MMPI) (Collet et al., 1990), or the Eysenck personality inventory (EPQ) (Zachariae et al., 2000). In contrast to the MMPI and the EPQ, the NEO-FFI has no scales to control for response biases such as social desirability or faking bad. Data obtained with the MMPI, however, argue against intentional bias in populations affected by tinnitus (Bayar et al., 2002; Marciano et al., 2003). As for the strong correlations between the trait ‘Neuroticism’, female gender (p ¼ .045), and age (negative correlation, p ¼ .024), others have shown that a decrease in ‘Neuroticism’ with age, especially in women, occurs independently of tinnitus when large cohorts are studied from the general population (Srivastava et al., 2003). A significant correlation of tinnitus severity was equally noted with depression. Depression is common in individuals with chronic tinnitus (Zoger et al., 2001), which may indicate that individuals with tinnitus have poor compensation strategies, or a predisposition for both conditions. Negative effects of depression on coping behaviors may manifest as nonhabituation to tinnitus symptoms (Reynolds et al., 2004), and a reduced drive to seek medical attention. At the same time, depression occurring together with tinnitus may render some interventions for tinnitus less effective, e.g. the
practice of cognitive behavioral therapy. A major emerging risk factor for depressive comorbidity is internal focus (Newman et al., 1997). Hallam et al. (1988) first postulated that attentional processes akin to obsessional ruminations play a key role in modulating the perceived handicap from tinnitus. Others have confirmed the joint contribution of depression, somatic perception, and temperament to the psychological strain defining the handicap from tinnitus (Perrig-Chiello and Gusset, 1996). Conclusions Significant correlations have emerged among the severity of tinnitus, depression, and two dimensions of personality. Tinnitus severity was predicted by low ‘Agreeableness’ and high ‘Neuroticism’, but the degree of correlation depended on which measure of severity was used. It remains to be seen whether the unhappy triad ‘‘depression, anxiety/‘Neuroticism’ and irritability/low ‘Agreeableness’’’ is an indicator of somatic comorbidity that may warrant adaptations of interventional techniques in individuals with chronic tinnitus. Abbreviations BDI NEO FFI THI TQ
Beck depression inventory NEO-five factor inventory tinnitus handicap inventory tinnitus questionnaire
Acknowledgments The authors wish to thank Sandra Pfluegl and Helene Niebling for assistance with data collection. The study was supported by a grant from the Tinnitus Research Initiative. References Andersson, G., Kaldo-Sandstrom, V., Strom, L. and Stromgren, T. (2003) Internet administration of the hospital anxiety and depression scale in a sample of tinnitus patients. J. Psychosom. Res., 55: 259–262.
225 Bayar, N., Oguzturk, O. and Koc, C. (2002) Minnesota multiphasic personality inventory profile of patients with subjective tinnitus. J. Otolaryngol., 31: 317–322. Beck, A.T., Steer, R.A. and Garbin, M.G. (1988) Psychometric properties of the Beck depression inventory: twenty-five years of evaluation. Clin. Psychol. Rev., 8: 77. Collet, L., Moussu, M.F., Disant, F., Ahami, T. and Morgon, A. (1990) Minnesota multiphasic personality inventory in tinnitus disorders. Audiology, 29: 101–106. Costa, P.T. and McCrae, R.R. (1985) The NEO Personality Inventory. Manual Form S and Form R. Psychological Assessment Resources, Odessa, FL. Dobie, R.A., Sakai, C.S., Sullivan, M.D., Katon, W.J. and Russo, J. (1993) Antidepressant treatment of tinnitus patients: report of a randomized clinical trial and clinical prediction of benefit. Am. J. Otol., 14: 18–23. Endler, N.S. and Kocovski, N.L. (2001) State and trait anxiety revisited. J. Anxiety. Disord., 15: 231–245. Goebel, G. and Hiller, W. (1994) The tinnitus questionnaire. A standard instrument for grading the degree of tinnitus. Results of a multicenter study with the tinnitus questionnaire. HNO, 42: 166–172. Halford, J.B. and Anderson, S.D. (1991) Tinnitus severity measured by a subjective scale, audiometry and clinical judgement. J. Laryngol. Otol., 105: 89–93. Hallam, R.S., Jakes, S.C. and Hinchcliffe, R. (1988) Cognitive variables in tinnitus annoyance. Br. J. Clin. Psychol., 27(Pt 3): 213–222. Harrop-Griffiths, J., Katon, W., Dobie, R., Sakai, C. and Russo, J. (1987) Chronic tinnitus: association with psychiatric diagnoses. J. Psychosom. Res., 31: 613–621. Hiller, W. and Goebel, G. (2004) Rapid assessment of tinnitusrelated psychological distress using the mini-TQ. Int. J. Audiol., 43: 600–604. Hiller, W., Janca, A. and Burke, K.C. (1997) Association between tinnitus and somatoform disorders. J. Psychosom. Res., 43: 613–624. Kleinjung, T., Fischer, B., Langguth, B., Sand, P.G., Hajak, G., Dvorakova, J. and Eichhammer, P. (2007) Validation of the German-version tinnitus handicap inventory (THI). Psychiatr. Prax., 34: 140–142. Langenbach, M., Olderog, M., Michel, O., Albus, C. and Kohle, K. (2005) Psychosocial and personality predictors of tinnitus-related distress. Gen. Hosp. Psychiatry, 27: 73–77. Marciano, E., Carrabba, L., Giannini, P., Sementina, C., Verde, P., Bruno, C., Di, P.G. and Ponsillo, N.G. (2003) Psychiatric comorbidity in a population of outpatients affected by tinnitus. Int. J. Audiol., 42: 4–9.
McCombe, A., Baguley, D., Coles, R., McKenna, L., McKinney, C. and Windle-Taylor, P. (2001) Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999. Clin. Otolaryngol., 26: 388–393. Meier, B.P. and Robinson, M.D. (2004) Does quick to blame mean quick to anger? The role of agreeableness in dissociating blame and anger. Pers. Soc. Psychol. Bull., 30: 856–867. Newman, C.W., Sandridge, S.A. and Jacobson, G.P. (1998) Psychometric adequacy of the tinnitus handicap inventory (THI) for evaluating treatment outcome. J. Am. Acad. Audiol., 9: 153–160. Newman, C.W., Wharton, J.A. and Jacobson, G.P. (1997) Self-focused and somatic attention in patients with tinnitus. J. Am. Acad. Audiol., 8: 143–149. Perrig-Chiello, P. and Gusset, S. (1996) Differential aspects of subjective burden of tinnitus aurium. Psychother. Psychosom. Med. Psychol., 46: 139–146. Reynolds, P., Gardner, D. and Lee, R. (2004) Tinnitus and psychological morbidity: a cross-sectional study to investigate psychological morbidity in tinnitus patients and its relationship with severity of symptoms and illness perceptions. Clin. Otolaryngol. Allied Sci., 29: 628–634. Russo, J., Katon, W., Sullivan, M., Clark, M. and Buchwald, D. (1994) Severity of somatization and its relationship to psychiatric disorders and personality. Psychosomatics, 35: 546–556. Sourgen, P.M. and Ross, E. (1998) Perceptions of tinnitus in a group of senior citizens. S. Afr. J. Commun. Disord., 45: 61–75. Srivastava, S., John, O.P., Gosling, S.D. and Potter, J. (2003) Development of personality in early and middle adulthood: set like plaster or persistent change? J. Pers. Soc. Psychol., 84: 1041–1053. Stobik, C., Weber, R.K., Munte, T.F., Walter, M. and Frommer, J. (2005) Evidence of psychosomatic influences in compensated and decompensated tinnitus. Int. J. Audiol., 44: 370–378. Sullivan, M., Katon, W., Russo, J., Dobie, R. and Sakai, C. (1993) A randomized trial of nortriptyline for severe chronic tinnitus. Effects on depression, disability, and tinnitus symptoms. Arch. Intern. Med., 153: 2251–2259. Zachariae, R., Mirz, F., Johansen, L.V., Andersen, S.E., Bjerring, P. and Pedersen, C.B. (2000) Reliability and validity of a Danish adaptation of the tinnitus handicap inventory. Scand. Audiol., 29: 37–43. Zoger, S., Svedlund, J. and Holgers, K.M. (2001) Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic. Audiology, 40: 133–140.