Self-reported and behavioral sound avoidance in tinnitus and ...

International Journal of Audiology 2012; 51: 611–617

Original Article

Self-reported and behavioral sound avoidance in tinnitus and hyperacusis subjects, and association with anxiety ratings Lena Blaesing & Birgit Kroener-Herwig Department of Clinical Psychology and Psychotherapy, Georg-August University of Göttingen, Germany

Abstract Objective: The purpose of the study was to analyse the role of sound avoidance and anxiety in tinnitus subjects with hyperacusis, defined as hypersensitivity to low to moderate intensity sounds. Design: A group of tinnitus subjects with hyperacusis was compared to tinnitus subjects without hyperacusis, and healthy controls. For assessing noise avoidance, a questionnaire was developed (noise avoidance questionnaire, NAQ) and the duration of self-exposure to a pure tone was assessed as a behavioral index. Different self-rating instruments concerning tinnitus (STI, TF-12), hyperacusis (GÜF), and anxiety (BAI, STAI-T) were used, as well as a psychoacoustic indicator of hyperacusis (ULL). Study sample: Fifty-six tinnitus subjects with/without hyperacusis and 30 controls without tinnitus and hyperacusis participated in the experiment. Results: The findings indicate that subjects with hyperacusis reported significantly more noise-related avoidance in daily life and show significantly shorter exposure to a pure tone than non-hyperacusic subjects, while discomfort was at the same level for each individual. Self-reported avoidance behavior correlated significantly with distress attributed to hyperacusis (r ⫽ 0.81), and with anxiety ratings. Conclusions: These results suggest that hyperacusis is associated with noise-related avoidance behavior and anxiety. Systematic exposure to sound could play a significant role in the treatment of hyperacusis.

Key Words: Hyperacusis; tinnitus; avoidance; noise avoidance questionnaire; hypersensitivity to sound; anxiety

Hyperacusis is described by the experience of a normal acoustic stimulus as being extremely loud or uncomfortable. Hyperacusis can be distinguished from other types of hypersensitivity to sound, such as recruitment, which is associated with an impairment of the outer hair cells, or to phonophobia. According to Schaaf et al (2003), hyperacusis is characterized by hypersensitivity to sounds of all frequencies at normal intensities. Subjects with recruitment, in contrast, are hypersensitive to sounds at the frequencies of their hearing impairment (Nelting et al, 2002), while phonophobia is characterized by hypersensitivity to specific sounds dependent on their meaning (Schaaf et al, 2003). In particular, tinnitus subjects are affected by hyperacusis, and about 40% report hypersensitivity to sound (Jastreboff et al, 1996; Johnson, 1999). Eighty-six percent of persons with hypersensitivity to sound also experience tinnitus (Anari et al, 1999). Some authors (Jastreboff & Hazell, 1993) assume hyperacusis to be a manifestation of an increased gain, which may also underlie the perception of tinnitus. According to these authors, hyperacusis is a pre-tinnitus state in some cases. However, there have been few attempts to identify the associated behavioral and emotional correlates that differentiate tinnitus subjects with hyperacusis from those without hyperacusis and from healthy controls.

Schaaf and Nelting (2003) assume that, at the beginning of the development of hyperacusis, several disorders can play a causal role, such as impairment of the facial nerve. According to these authors, maintenance and exacerbation of hyperacusis is compounded by avoidance of sound and increased anxiety. By reducing normal auditory exposure, in order to avoid discomfort, hyperacusis may be increased (Baguley, 2003), which in turn may lead to increased avoidance of sound. Thus, the patient can be caught in a vicious circle of sound avoidance and hyperacusis (Schaaf & Nelting, 2003). Some evidence for the association between reduced acoustic input and auditory sensitivity is provided by studies on the plasticity of the auditory system. It is suggested that loudness perception is controlled by a central gain and depends on the average level of sensory input (Noreña & Chery-Croze, 2007). This assumption was supported in a study by Formby et al (2003), in which ten participants over two weeks used either ear plugs, which reduced auditory input, or noise generators, which increased the auditory input by emitting a constant noise. The loudness perception of the participants was appraised by category loudness scaling before and after this intervention. After the treatment, the participants in the noise generator condition needed higher acoustical input to achieve the same loudness judgments as before. In contrast, the participants who used earplugs delivered higher

Correspondence: Lena Blaesing, Georg-Elias-Mueller Department of Psychology and Psychotherapy, Georg-August University of Göttingen, Goßlerstraße 14, 37073 Göttingen, Germany.E-mail: [email protected] (Received 28 July 2011; accepted 1 February 2012) ISSN 1499-2027 print/ISSN 1708-8186 online © 2012 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2012.664290

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L. Blaesing & B. Kroener-Herwig

Abbreviations BAI GÜF NAQ PHQ-D STAI STAI-T STI TF-12 ULL

Beck anxiety inventory Questionnaire on hypersensitivity to sound Noise avoidance questionnaire Patient health questionnaire, German version State-trait-anxiety inventory Trait scale of state-trait-anxiety inventory Structured tinnitus interview Mini-tinnitus questionnaire Uncomfortable loudness level

found a significantly higher rate of anxiety disorders in subjects with tinnitus and hyperacusis than in tinnitus subjects without hyperacusis. According to these findings, it is hypothesized that tinnitus subjects with hyperacusis are more often affected by comorbid anxiety disorders than non-hyperacusic subjects with and without tinnitus. The purpose of this study was to empirically analyse the relationship between sound avoidance and anxiety in tinnitus subjects with hyperacusis in comparison with tinnitus subjects without hyperacusis and healthy controls.

Methods Sample loudness judgments, as before, for the same acoustical input. Some evidence for the role of avoidance in subjects with hyperacusis is given by our recent study (Blaesing et al, 2010) in which we analysed associations between the items in the questionnaire on hypersensitivity to sound (Geräuschüberempfindlichkeitsfragebogen, GÜF; Nelting & Finlayson, 2004) with other methods of assessing hyperacusis (uncomfortable loudness level for tones and white noise, category loudness scaling, self-reported severity of hyperacusis). One of the items with high convergent validity was: I have to avoid certain sounds. This provides some evidence for the role of noise avoidance in subjects with hyperacusis. According to these results, it is assumed that subjects with hypersensitivity to sound exhibit more avoidance of sound than tinnitus subjects without hyperacusis and healthy persons. Our intent was to find empirical evidence for this assumption based on self-report and behavioral parameters of noiserelated avoidance. As there is no instrument available to assess noise avoidance, a new self-report questionnaire is introduced (Table 1). Furthermore, it is assumed that behavioral and self-reported avoidance of sound is positively correlated to the distress attributed to hyperacusis and negatively correlated to the uncomfortable loudness level (ULL). According to our previous study (Blaesing et al, 2010), another item of the GÜF with high convergent validity was: I am very scared of noise. Some authors (e.g. Schaaf & Nelting, 2003) assume an association between general anxiety and hyperacusis. Some empirical evidence was presented by Persson et al (2007), who reported a positive correlation between noise sensitivity and trait anxiety in a public health survey. Blomberg et al (2006) also found a significant positive correlation between hyperacusis and a questionnaire on fears in a sample of individuals with Williams syndrome, a genetic neurodevelopmental disorder with different symptoms, including hypersensitivity to sound. According to these results, it is assumed that anxiety is linked to hyperacusis and, as a consequence, tinnitus subjects with hyperacusis report more current anxiety symptoms and more general anxiety than tinnitus subjects without hyperacusis and healthy persons. Furthermore, it is hypothesized that current anxiety symptoms and general anxiety are positively correlated to the distress related to hyperacusis and negatively correlated to the ULL. In addition, it is assumed that the relationship between sound avoidance and distress due to hyperacusis is moderated by anxiety, as anxiety itself can be a factor in influencing the sensitivity of the auditory system. Thus, noise-related avoidance could lead to more distress due to hyperacusis in highly anxious people than in those with lower levels of anxiety, despite equal levels of avoidance. According to Sammeth et al (2000), subjects with hyperacusis are particularly vulnerable to anxiety disorders. Goebel and Floetzinger (2008), in a sample of inpatients at a behavioral medicine clinic,

Subjects were invited to participate through the local newspaper, websites, and University campus notice-boards. Interested individuals were asked to contact the researcher by email or telephone. Inclusion and exclusion criteria were subsequently checked during a telephone interview and directly before the experiment (hearing thresholds). The inclusion criterion for the tinnitus subjects was self-reported tinnitus. Tinnitus subjects were allocated to the hyperacusis group (HT) if they reported increased sensitivity to various sounds of all frequencies at normal intensities. Subjects were excluded if they

Table 1. Noise avoidance questionnaire (NAQ; English translation). Item

In order to expose myself to no or less noise…

1 2

13 14 15

I cancel professional commitments and appointments I use hearing protection at work and/or during my leisure time even when there is actually no noise, as for example noise from a machine I avoid visiting friends I withdraw I cancel appointments with family and friends I ask my colleagues to work more quietly/to be more quiet I leave an event/occasion before time I prefer to stay at home during my leisure time I break off meetings with friends I avoid listening to music or to the radio I stop activities that I am performing I perform activities only with hearing protection even when there is actually no noise arising, as for example noise from a machine I ask my family to be more quiet I avoid the company of others I avoid watching television

Item 16 17 18 19 20 21 22 23 24 25

In order to expose myself to no or less noise I avoid… Public facilities, e.g. swimming pools Cinema or theatre visits Department stores or supermarkets Restaurants Bars or clubs Train stations or airports Festivities or parties Public events, e.g. football games Concerts Street noise

3 4 5 6 7 8 9 10 11 12

Note. Each item is rated on a five-point scale: never (0), rarely (1), occasionally/sometimes (2), often (3), very often/always (4).

Avoidance and anxiety in hyperacusis subjects reported hypersensitivity to just one or a few specific sounds, as this is considered an indicator of phonophobia. Subjects were also excluded if they reported hypersensitivity to sounds at one or a few specific frequencies, as this could be an indicator of recruitment. Tinnitus subjects not reporting sounds at normal intensities as uncomfortable or painful were allocated to the tinnitus (alone) group (T). The group of healthy controls (C) was recruited based on their selfdescription of the absence of tinnitus and hypersensitivity to sound. The exclusion criterion for all groups was hearing impairment in one or both ears (defined as: mean hearing threshold level in the frequency range from 500 to 3000 Hz ⬎ 40, or hearing threshold at 2000 Hz ⬎ 40). This frequency range was chosen according to the range of speech defined by the guidelines on non-physician care and medical aids (Heil- und Hilfsmittelrichtlinien) (e.g. Seidler, 1996). Pure-tone hearing thresholds were tested at different frequencies (500, 750, 1000, 1500, 2000, and 3000 Hz) for each ear separately using the AS608e system (Interacoustics). The HT group was comprised of 28 tinnitus subjects (9 males, 19 females) between 24 and 66 years of age (mean age ⫽ 49.14, sd ⫽ 11.04). Twenty-eight tinnitus subjects without hyperacusis (17 males, 11 females) between 18 and 74 years of age (mean age ⫽ 48.75, sd ⫽ 12.06) constituted the T group, and 30 controls (15 males, 15 females) between 23 and 71 years of age (mean age ⫽ 46.40, sd ⫽ 11.30) comprised the C group. There were no significant differences between the groups in terms of age (F(2, 83) ⫽ 0.490, p ⫽ 0.615) or gender (χ2(2) ⫽ 4.681, p ⫽ 0.096). The mean hearing threshold in the frequencies from 500 to 3000 Hz in the sample was 8.71 Hz (sd ⫽ 6.64); there was no significant difference between the groups (F(2,83) ⫽ 1.172, p ⫽ 0.315).

Assessment of hyperacusis For the diagnosis of hyperacusis, items of the structured tinnitus interview (STI) (Goebel & Hiller, 2001) were used; the items ask whether a patient experiences low to moderate noise as uncomfortable or painful, and whether increased sensitivity is limited to specific sounds. As an audiological correlate of hyperacusis, the ULL was measured while presenting sounds over earphones at increasing intensities. The procedure was conducted separately for each ear with pure tones at the frequencies 500, 1000, 2000, and 3000 Hz. The participants received instruction to indicate the level at which they experienced the tone as uncomfortable by pressing a button. The subjective distress related to hyperacusis was assessed by the GÜF (Nelting & Finlayson, 2004). The GÜF consists of 15 items to determine the experienced annoyance on a four-point rating scale (0 ⫽ never correct, 3 ⫽ always correct), for example: Since I have become hypersensitive to sound I no longer enjoy music. On the basis of the GÜF-total-score, the distress related to hypersensitivity to sound was categorized into four levels (0–9 ⫽ mild, 10–15 ⫽ moderate, 16–23 ⫽ serious, 24–45 ⫽ severe) (Nelting & Finlayson, 2004).

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Assessment of sound avoidance The noise avoidance questionnaire (NAQ), a self-report inventory asking about the avoidance of sound in daily life, was developed and validated by the authors for use in the study (Table 1). The construction was guided by the avoidance-endurance-questionnaire (Hasenbring et al, 2009), which assesses avoidance behavior in response to pain. Also, the mobility inventory (Ehlers et al, 2001), which assesses the extent of agoraphobic avoidance behavior, was used as a model. The NAQ was evaluated in a population sample of 74 subjects (34 males, 40 females) between 22 and 78 years of age (mean age ⫽ 51.76, sd ⫽ 12.90). According to the KolmogorovSmirnov-Test, the NAQ-scores in the evaluation were normally distributed (p ⫽ 0.246). Cronbach’s alpha was 0.904. To analyse validity, correlations of the NAQ with other questionnaires were assessed. Some evidence for convergent validity was given by the correlation of the NAQ with the GÜF (r ⫽ 0.612, p ⬍ 0.001). Some evidence for divergent validity was given by the non-significant correlation of the NAQ with the subscale agreeableness of the NEO five factor inventory (Costa & McCrae, 1989; German version: Borkenau & Ostendorf, 1993) (r ⫽ 0.039, p ⫽ 0.739). After item analyses of the NAQ, four items with insufficient item totalcorrelations (r ⬍ 0.30) were revised or removed, so that the final version of the questionnaire contained 25 items. The frequency of noise-related avoidance was rated on a five-point scale (0 ⫽ never; 4 ⫽ very often/always), for example: In order to expose myself to no or less noise, I avoid visiting friends. Cronbach’s alpha for the present data was 0.96. To assess a behavioral index of noise avoidance, all subjects were exposed to a tone in a laboratory session. Based on the procedure used by Philips & Hunter (1982) and Martin et al (2006), the participants were exposed to a pure tone of 2000 Hz (two minutes and 75 dB at most). They were instructed to indicate the point in time at which they did not want to hear it any longer. The tone was presented over earphones using the AS608e system (Interacoustics). After initiating the tone presentation, the participants indicated the point at which they did not want to hear it any longer by pressing a button. The time from initiating to cessation was measured in seconds. The avoidance test was conducted for both ears separately and the tolerance time was averaged over both ears. In order to control for discomfort, following Vernon (1987), the intensity level at which subjects turned down the volume of their television using a tone of 2000 Hz with increasing intensity was assessed for all participants prior to the sound presentation. This was subsequently the intensity level at which the tone was presented until the participants gave the signal to switch it off. Only those participants who indicated a level below 75 dB were included in the analysis (N ⫽ 73), because this level was chosen as the highest intensity to ensure that the probable maximum presentation of two minutes would be tolerable without damaging the auditory system.

Assessment of anxiety Assessment of tinnitus impairment The severity of the impairment caused by tinnitus was assessed by means of the mini-tinnitus questionnaire (TF-12), an abridged formal version of the German tinnitus questionnaire (Hiller & Goebel, 2004), originally constructed by Hallam et al (1988). The TF-12 consists of 12 items giving a total score between 0 and 24 points which can be used for categorization into four grades (0–7 ⫽ mild, 8–12 ⫽ moderate, 13–18 ⫽ serious, 19–24 ⫽ severe).

For assessing the actual severity of self-reported anxiety symptoms in the previous week, the Beck anxiety inventory (BAI, Beck & Steer, 1993) was presented. For assessing anxiety as the dispositional tendency to evaluate situations as threatening (Spielberger, 1972), the trait scale of the state-trait-anxiety-inventory (STAI, Spielberger et al, 1970; German version: Laux et al, 1981) was used. The PRIME-MD patient health questionnaire (Spitzer et al, 1999; German version: PHQ-D, Löwe et al, 2002) was used to

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screen for anxiety disorders based on the criteria of the diagnostic and statistical manual of mental disorders, IV (DSM-IV, APA, 2000).

Procedure After the criteria were checked in a telephone interview and an individual was assigned to one of the study groups, the questionnaires (TF-12, GÜF, NAQ, BAI, STAI-T, and PHQ-D) were sent to him/ her by mail. After completing and returning the questionnaires, he/ she was called in for an assessment. All participants were asked to give written informed consent to participate. Next they completed the state scale of the STAI (results will be presented elsewhere). Subsequently, pure-tone hearing thresholds and the ULL were assessed. The behavioral avoidance test was conducted, followed by the completion of the state scale of the STAI. Thereafter, the participants appraised the valence and arousal of different everyday sounds (results will be presented elsewhere). For travel expenses, participants were paid 20–80 Euros. Ethical approval for the study was obtained from the Ethics Committee of the Georg-Elias-Mueller Institute for Psychology.

T groups (HT ⬎ T) (T(83) ⫽ ⫺ 5.791, p ⬍ 0.001) and between the HT and C groups (HT ⬎ C) (T(83) ⫽ ⫺ 5.984, p ⬍ 0.001). Subjects in the T and C groups did not differ (T(83) ⫽ ⫺ 0.093, p ⫽ 0.926) (Table 2). Significant differences between the groups were found in the GÜF-scores (F(2, 83) ⫽ 47.294, p ⬍ 0.001) (Table 2). Separate planned contrasts showed significant differences between the HT and T groups (HT ⬎ T) (T(83) ⫽ 6.139, p ⬍ 0.001), between the HT and C groups (HT ⬎ C) (T(83) ⫽ 9.617, p ⬍ 0.001), and between the T and C groups (T ⬎ C) (T(83) ⫽ 3.373, p ⫽ 0.001) (Table 2). According to the grading proposed by Nelting and Finlayson (2004) the mean GÜF scores in the C and T groups corresponded to low distress caused by hypersensitivity to sound, whereas the mean GÜF score in the HT group corresponded to serious distress caused by hypersensitivity to sound.

Tinnitus impairment The mean TF-12 score in the tinnitus-affected groups corresponded to a moderate impairment due to tinnitus (Table 2). There was no significant difference in the mean TF-12 score (T(54) ⫽ ⫺ 1.361, p ⫽ 0.179) between the HT and T groups. No difference was found in the frequency distribution of subjects in each of the four grades of tinnitus impairment (χ2(3) ⫽ 4.428, p ⫽ 0.219) (Table 3).

Data analysis ANOVA, planned contrasts, and chi-square tests were calculated to analyse differences between the groups. Correlations were analysed using the Pearson correlation coefficient. Moderator effects were determined by conducting hierarchical linear regressions using standardized z-scores for the predictor and moderator variables. All calculations were conducted by means of the Predictive Analytics Software (PASW Statistics 18). The significance level was set at p ⱕ 0.05.

Results Hyperacusis ANOVA showed significant differences between the groups in the mean ULL (F(2, 83) ⫽ 22.996, p ⬍ 0.001) (Table 2). Separate planned contrasts revealed significant differences between the HT and Table 2. Means and standard deviations of parameters of tinnitus, hyperacusis, avoidance, and anxiety. Mean (standard deviation) Parameter ULL GÜF TF-12 NAQ Intensity of test tone Sound tolerance of test tone BAI STAI-T

HT

T

C

66.33a (14.97) 19.68a (9.08) 11.79a (5.25) 38.54a (19.57) 55.71a (11.65) 12.75a (23.51)

87.53b (13.09) 8.89b (6.39) 9.71a (6.10) 13.04b (12.43) 73.77b (13.07) 38.93b (49.11)

87.86b (12.99) 3.07c (2.97) – 6.1b (6.34) 67.35b (13.64) 52.88b (50.07)

15.57a (9.86) 45.21a (10.11)

8.11b (7.00) 39.86b (9.00)

6.23b (8.22) 33.73c (7.62)

Note. Means in the same row that do not share subscripts differ significantly at p ⬍ 0.05 in planned contrasts. ULL: Uncomfortable loudness level. GÜF: Questionnaire on hypersensitivity to sound. TF-12: Mini-tinnitus questionnaire. NAQ: Noise avoidance questionnaire. BAI: Beck anxiety inventory. STAI-T: Trait scale of state-trait-anxiety-inventory. HT: Tinnitus subjects with hyperacusis. T: Tinnitus subjects without hyperacusis. C: Controls.

Avoidance of sound It was hypothesized that subjects in the HT group would report and show more noise-related avoidance than subjects in the T and C groups. ANOVA showed significant differences between the three groups in the NAQ scores (F(2, 83) ⫽ 44.112, p ⬍ 0.001, η2 ⫽ 0.515). Separate planned contrasts revealed significant differences between the subjects in the HT and T groups (HT ⬎ T) (T(83) ⫽ 6.940, p ⬍ 0.001, d ⫽ 1.555) and the HT and C groups (HT ⬎ C) (T(83) ⫽ 8.979, p ⬍ 0.001, d ⫽ 2.262). Subjects in the T and C groups did not differ (T(83) ⫽ 1.920, p ⫽ 0.058) (see Table 2 for descriptive data). Significant differences were found between groups regarding the intensity level of the tone at the same discomfort level (the intensity at which the television would be turned down) (F(2, 83) ⫽ 14.251, p ⬍ 0.001, η2 ⫽ 0.256) (Table 2). Separate planned contrasts showed significant differences in the intensity level between the HT and T groups (HT ⬍ T) (T(83) ⫽ ⫺ 5.263, p ⬍ 0.001, d ⫽ 1.458), and between the HT and C groups (HT ⬍ C) (T(83) ⫽ ⫺ 3.450, p ⫽ 0.001, d ⫽ 0.915). No significant differences were found between subjects in the T and C groups (T(83) ⫽ 1.903, p ⫽ 0.061). The avoidance test showed that the groups differed significantly in the duration of time over which the test tone was tolerated (F(2, 70) ⫽ 6.379, p ⫽ 0.003, η2 ⫽ 0.154). Significant differences were found between subjects in the HT and T groups (HT ⬍ T) (T(70) ⫽ ⫺ 2.151, p ⫽ 0.035, d ⫽ 0.720), and in the HT and C groups (HT ⬍ C) (T(70) ⫽ ⫺ 3.509, p ⫽ 0.001, d ⫽ 1.046). Subjects in the T and C groups did not differ (T(70) ⫽ ⫺ 1.119, p ⫽ 0.267). Large standard deviations were found for all three groups (Table 2). A correlational analysis to examine the associations between avoidance and hyperacusis showed a highly significant positive correlation between the NAQ and the GÜF (r ⫽ 0.812, p ⬍ 0.001), and a significant negative correlation between the NAQ and the ULL (r ⫽ ⫺ 0.486, p ⬍ 0.001). A significant negative relationship was found between tolerance (in seconds) for the test tone and the GÜF (r ⫽ ⫺ 0.346, p ⫽ 0.003), and a significant positive relationship was found between tolerance for the test tone and the ULL (r ⫽ 0.378, p ⫽ 0.001).

Avoidance and anxiety in hyperacusis subjects Table 3. Frequency distribution of tinnitus impairment according to TF-12 in tinnitus subjects with and without hyperacusis. Grade of tinnitus impairment

HT

T

1 ⫽ light 2 ⫽ moderate 3 ⫽ serious 4 ⫽ severe

5 13 7 3

12 9 4 3

TF-12: Mini-tinnitus questionnaire. HT: Tinnitus subjects with hyperacusis. T: Tinnitus subjects without hyperacusis.

Anxiety ANOVA showed significant differences between the groups in the BAI-scores (F(2, 83) ⫽ 9.800, p ⬍ 0.001, η2 ⫽ 0.191). Separate planned contrasts revealed significant differences between the subjects in the HT and T groups (HT ⬎ T) (T(83) ⫽ 3.312, p ⫽ 0.001, d ⫽ 0.873), and in the HT and C groups (HT ⬎ C) (T(83) ⫽ 4.214, p ⬍ 0.001, d ⫽ 1.033). No significant difference was found between the subjects in the T and C groups (T(83) ⫽ 0.846, p ⫽ 0.400) (Table 2). ANOVA revealed significant differences between the groups in terms of trait anxiety (STAI-T) (F(2, 83) ⫽ 11.993, p ⬍ 0.001, η2 ⫽ 0.224). Significant differences were found between the subjects in the HT and T groups (HT ⬎ T) (T(83) ⫽ 2.243, p ⫽ 0.028, d ⫽ 0.560), in the HT and C groups (HT ⬎ C) (T(83) ⫽ 4.889, p ⬍ 0.001, d ⫽ 1.289), and in the T and C groups (T ⬎ C) (T(83) ⫽ 2.608, p ⫽ 0.011, d ⫽ 0.737) (Table 2). A correlational analysis of the association between hyperacusis and anxiety revealed a significant positive relationship between the GÜF-scores and the BAI (r ⫽ 0.622, p ⬍ 0.001), and between the GÜF-scores and the STAI-T (r ⫽ 0.646, p ⬍ 0.001). The ULL was significantly negatively related to the BAI-score (r ⫽ ⫺ 0.352, p ⫽ 0.001) and the STAI-T-score (r ⫽ ⫺ 0.386, p ⬍ 0.001). It was hypothesized that anxiety acts as a moderator of the relationship between sound avoidance (NAQ, tolerance for a pure tone) and distress due to hyperacusis (GÜF). A significant moderation effect of anxiety is assumed if hierarchical linear regression reveals a significant contribution of an interaction between sound avoidance and anxiety to the prediction of distress due to hyperacusis (Table 4). The relationship between avoidance (NAQ, tolerance for a pure tone) and the GÜF was not significantly moderated by anxiety (BAI, STAI-T) (p ⬎ 0.05). There was no significant association between the groups and anxiety disorders (χ2(2) ⫽ 1.799, p ⫽ 0.407) assessed by means of the PHQ-D.

Discussion Avoidance in tinnitus subjects with hyperacusis It has often been assumed (Baguley, 2003; Schaaf & Nelting, 2003) that avoidance of sound is a mechanism for maintaining and exacerbating hyperacusis. Yet, there is a lack of empirical evidence that tinnitus subjects with self-reported hypersensitivity to sound show more noise-related avoidance in their daily life than healthy controls or tinnitus subjects without hyperacusis. This hypothesis was tested by a recently constructed questionnaire (noise avoidance questionnaire, NAQ), since there was no comparable instrument available. A high Cronbach’s alpha indicated a good internal consistency of the NAQ. Self-reported avoidance behavior assessed by means of the NAQ was, as expected, associated with a high level of distress as

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measured by the questionnaire on hypersensitivity to sound (GÜF), and a low intensity level at which sounds were perceived as uncomfortable, indicating convergent validity of the NAQ. Subjects in the HT group scored significantly higher on the NAQ than subjects in the T and C groups; that is, they perceived themselves as frequently avoiding sounds in their daily life in different situations. This is interpreted as indicating greater noise-related avoidance in hyperacusic subjects. This basic finding supports the idea of sound avoidance as a behavioral component and possible mechanism for the maintenance of hyperacusis. Subjects in the HT group had shorter tolerance to a continuous tone than T or C subjects, despite equivalent discomfort levels. These findings support the assumption of stronger behavioral avoidance tendencies in tinnitus subjects also complaining of hyperacusis. The hypothesis indicates that avoidance of situations leads to a reduction in auditory input and a decrease in activities and situations which are associated with sound and noise. As avoidance is associated with the degree of hyperacusis, avoidance may worsen the hypersensitivity to sound. Thus, avoidance may create a negative feedback circuit as avoidance increases sensitivity. When the treatment of hyperacusis is the goal, this vicious circle has to be broken. Noreña and Chery-Croze (2007) showed that after 15 weeks of daily confrontation with pure tones, participants perceived tones as comfortable which were previously judged to be loud. Ziegler et al (2000) found a significant increase in the uncomfortable loudness level (ULL) in 41 patients with tinnitus and hyperacusis after multimodal treatment, which included increased noise exposure through noise generators or hearing aids. Woelk and Seefeld (1999) reported that the ULL and the dynamic range of 23 patients with hyperacusis increased after tinnitus retraining therapy, including the use of noise generators. In summary, these studies support the

Table 4. Hierarchical regression analysis testing anxiety as moderator between noise-related avoidance and distress caused by hyperacusis. Variables in the analyses Criterion GÜF Step 1: NAQ Step 2: BAI Step 3: NAQ ⫻ BAI Step 1: NAQ Step 2: STAI-T Step 3: NAQ ⫻ STAI-T Step 1: ST Step 2: BAI Step 3: ST ⫻ BAI Step 1: ST Step 2: STAI-T Step 3: ST ⫻ STAI-T

R2

ΔR2

B

SE B

β

t

0.659 0.659** 0.691 0.032** 0.705 0.014

5.820 2.001 1.041

0.774 0.699 0.534

0.614 0.212 0.138

7.521** 2.863** 1.950

0.659 0.659** 0.738 0.079** 0.748 0.010

5.811 3.260 1.112

0.638 0.620 0.623

0.613 0.338 0.105

9.113** 5.257** 1.786

0.120** 0.294** 0.013 0.120** 0.300** 0.029

⫺ 2.497 4.787 ⫺ 1.432 ⫺ 1.906 5.698 ⫺ 1.706

0.933 0.950 1.127 0.966 0.942 0.890

⫺ 0.256 0.507 ⫺ 0.126 ⫺ 0.195 0.577 ⫺ 0.178

⫺ 2.676** 5.038** ⫺ 1.270 ⫺ 1.972* 6.048** ⫺ 1.917

0.120 0.414 0.427 0.120 0.419 0.449

Note. Level of significance: *p ⱕ 0.05, **p ⱕ 0.01. GÜF: Questionnaire on hypersensitivity to sound. NAQ: Noise avoidance questionnaire. BAI: Beck anxiety inventory. STAI-T: Trait scale of state-trait-anxiety-inventory. ST: Sound tolerance (seconds) of test tone. R2: Measure of how much of the variability in the outcome is accounted for by the predictor. ΔR2: Change in R2. B: Regression coefficient: contribution of each predictor to the prediction of the criterion. SE B: Standard error of B. β: Standardized B.

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conclusion that avoidance leads to heightened noise sensitivity and confrontation with auditory input helps to reduce it. The NAQ therefore provides a new instrument to assess the extent of avoidance in a patient and an outline of the specific situations and activities that are avoided by this person, which is useful for individual therapy schedules.

28th Symposium der Fachgruppe Klinische Psychologie und Psychotherapie der Deutschen Gesellschaft für Psychologie, from 13 to 15 May 2010 in Mainz, Germany. An abstract of this contribution was published in Zeitschrift für Klinische Psychologie und Psychotherapie (abstract volume). The results were presented at the 7th Workshopkongress der Fachgruppe Klinische Psychologie und Psychotherapie der Deutschen Gesellschaft für Psychologie, from 2 to 4 June 2011 in Berlin, Germany.

Anxiety in tinnitus subjects with hyperacusis As hypothesized, subjects in the HT group showed significantly more current anxiety symptoms and trait anxiety than those in the T and C groups. Considerable differences were found between subjects in the HT group compared with those in the T and C groups in terms of anxiety symptoms assessed by means of the Beck anxiety inventory (BAI), while the T and C groups did not differ significantly. Trait anxiety assessed by means of the state trait anxiety inventory (trait scale) (STAI-T) was higher in the HT group compared with those in the T and C groups, and subjects in the T group also scored significantly higher than those in the C group. The BAI assesses actual anxiety symptoms and particularly considers the somatic symptoms of anxiety (e.g. numbness or tingling, feeling hot, wobbliness in the legs, etc.), while the STAI-T measures trait anxiety and focuses more on the cognitive aspects of anxiety (e.g. I lack self-confidence). The somatic symptoms of anxiety seem to differentiate particularly between hyperacusis subjects and those without hyperacusis. As expected, anxiety was positively correlated to the distress caused by hyperacusis and negatively to the level of intensity at which sounds were perceived as uncomfortable. Comparable associations between the features of hyperacusis and both measures of anxiety were found, suggesting that the anxiety symptoms and trait anxiety are associated with hyperacusis, but do not act as a moderator between noise avoidance and distress due to hyperacusis. Contrary to our hypothesis, we did not find a higher rate of anxiety disorders in our sample of hyperacusis subjects than that reported in a study by Goebel and Floetzinger (2008), possibly because of the higher rate of psychopathology in their sample of inpatients at a psychosomatic clinic.

Limitations Generalization of our results is limited to subjects with hyperacusis and tinnitus. Thus, future studies should include hyperacusisaffected individuals without tinnitus, to see whether our results can be replicated. As our sample consisted of voluntary participants, it is likely to represent more extreme cases within the population.

Conclusions According to the present findings, hyperacusis is associated with sound avoidance. It has been argued that avoidance maintains or even worsens hypersensitivity to sound. Thus, confrontation with avoided situations and activities should be considered within a treatment programme for hyperacusis. This is particularly important for highly anxious subjects, who experience more distress due to hyperacusis, which may increase sound sensitivity in the auditory system as a consequence of sound avoidance.

Acknowledgements We thank Dr. Antonia Barke for her help in translating the noise avoidance questionnaire. The study design was presented at the

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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