Pain and Stress Levels in Tinnitus Patients. Introduction. the human experience (US Department of Health and Human Services, 2014).

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1 Pain and Stress Levels in Tinnitus Patients Introduction Mental health (MH) specifically refers to the quality of emotional, psychological and social well-being that determines how well an individual copes with the stressors that define the human experience (US Department of Health and Human Services, 214). Studies have shown that subjects affected by chronic pain and/or stress generally demonstrate poor coping strategies (REF). Not surprisingly then, strong relationships between chronic pain and mental health and between chronic stress and mental health have been demonstrated (REFS), and the physiological mechanisms for these relationships have been suggested (Blackburn-Munro and Blackburn-Munro, 21). Many individuals with tinnitus have coexisting mental health disorders and that those tinnitus patients with coexisting mental health disorders experience greater tinnitus-related disturbance than those without (Benton, 211). Chronic Pain in the General Population The National Center for Health Statistics (26) estimates that the prevalence of chronic pain in the general population is approximately 3% for ages and 21% for ages 65 and older. Blyth et al (21) reported gender differences based on over 17, phone interviews: 17% of males and 2% of females reported chronic pain. Johannes et al (21) utilized an internet-based survey with over 27, responses and the prevalence of pain among adults in the United States was 31%. Ratings were based on -1 scales where meant no pain and 1 indicated the worst pain imaginable. They also

2 identified gender differences with higher prevalence of chronic pain among females (34%) than males (27%). They also reported that 32% of adult males with pain reported severe chronic pain (ratings of 7 or higher on the -1 scale). Breivik et al (26) evaluated the prevalence of chronic pain in 15 countries and Europe based on screening interviews from over 46, subjects and found that 19% experienced chronic pain. Ratings were based on 1-1 scales where 1 meant no pain and 1 indicated the worst pain imaginable. Further in-depth interviews with 4839 subjects revealed moderate pain in 66% of subjects (ratings of 5-7 on the 1-1 scale) and severe pain in 34% of subjects (ratings of 8-1 on the 1-1 scale). Moller (27) and DeRidder and Van de Heyning (27) argued that the similarities between chronic pain and chronic tinnitus add further evidence to the theory that central nervous system plasticity plays a role in both conditions. White (214) reported that there is an unusually high incidence of chronic pain among patients who are distressed by tinnitus: 42% of her subjects who scored 17 or higher on the Tinnitus Reaction Questionnaire (Wilson et al, 1995) reported severe chronic pain and another 32% reported moderate chronic pain. Stress in the General Population Altaf et al (214) reported that 27% of males and 26% of females report experiencing stress; 7% of males and 1% of females reported severe stress. The American

3 Psychological Association, or APA (212), surveyed over 12 people in four age groups regarding stress and related factors. A summary of the relevant findings include: Persons with depression reported significantly higher stress levels than those without depression. Most adults report that their stress is increasing rather than decreasing. Over half of adults reported personal health problems as a source of stress. Fewer than one third of adults state they are doing a good job managing or reducing stress when it occurs. Almost half of adults reported lying awake at night being unable to sleep related to stress. Women report higher stress levels than men, and men are less likely to report that stress has a strong impact on their health. The APA study (212) provided specific information regarding Stress in Atlanta. The key findings were that Atlanta residents average stress level is similar to that of the nation as a whole and that nearly 75% of Atlanta residents report that work and the economy are major stressors, and over half report that job stability is a major stressor. Study Rationale Imaging studies reveal that there is significant overlap among brain centers responsible for mental health issues and tinnitus-related distress (Langguth & Landgrebe, 211). It therefore is not surprising that many individuals with tinnitus have coexisting mental health disorders and that those tinnitus patients with coexisting mental health disorders experience greater tinnitus-related disturbance than those without (Benton, 211). Because there are relationships between chronic pain and mental health and between stress and mental health,

4 and given the strong bi-directional relationship between mental health and tinnitus, we reasoned that both chronic pain and stress also may be related to tinnitus-related distress and/or perceived tinnitus severity. Method At the Atlanta VA Audiology Clinic, -1 scales visual analog scales frequently are utilized as a measure of patient concerns. Although such ratings have reported limitations, including the possible impact of social, contextual and cognitive issues, they also have major practical advantages in terms of not requiring any physical materials and terms of widespread acceptance in clinical practice (Bayer, 29). Lesage et al (212) reported that a visual analog scale was at least as discriminating as a questionnaire when it comes to highlighting differences in stress levels. The NIH Pain Consortium (215) provides a the use of a -1 visual analog scale for reporting chronic pain levels. Benton (REF) reported that a -1 scale also was valid for reporting tinnitus-related distress. On these three -1 scales, ratings of 7-1 are considered indicative of a severe problem. Thirty-eight (38) consecutive subjects who attended Progressive Tinnitus Management Level 3, Group Education, completed brief questionnaires prior to program presentation which included items related to perceived stress levels, chronic pain levels, and tinnitus- related distress, as well as the PHQ2 mental health screening questionnaire (Appendix A).

5 Findings Table 1 shows the mean scores and ratings (and standard deviations) for all questionnaire items. The values reveal that tinnitus subjects as a whole appear to experience significant comorbidities. Measure Range of Scores or Ratings Mean Score or Response (SD) PHQ2 (-6) (2.23) Awareness % (-1%) 1% 87.2% (21.9%) Disturbance % (-1%) 1% 81.1% (21.3%) Problem Level (-1) (1.76) Pain Level (-1) (2.17) Stress Level (-1) (2.33) Table 1. Mean scores and ratings for all questionnaire items. We then separated the 38 subjects into groups based on their subjective ratings: those whose ratings were -6 and those whose ratings were 7-1. The number of subjects falling into each score range is shown in Table 2. We then compared the groups mean ratings on the various measures to identify those factors which may further describe subjects with disturbing tinnitus. Correlations also were performed to identify relationships among the various measures.

6 Number of Subjects Rating = -6 Rating = Problem Tinn Size Problem Pain Level Stress Level Figure 2. The number of subjects rating their Tinnitus Problem, Pain Level and Stress Level -6 or 7-1. Tinnitus Problem Ratings We were unable to analyze the two groups based on Tinnitus Problem ratings of -6 and 7-1 because only four of the subjects (11%) rated their tinnitus problem as -6 on the -1 scale. Patients who have progressed to PTM Level 3, Group Education, are typically experiencing severe tinnitus-related distress and so lower Tinnitus Problem ratings would not be expected. Figure 3 provides the frequency of Tinnitus Problem Ratings provided by the 38 subjects; 89.5% of subjects rated their tinnitus problem as a 7 or greater.

7 Number of Subjects Number of Subjects 12 Tinnitus Problem Ratings None Mild Moderate Severe Figure 3. The frequency of Tinnitus Problem ratings provided by 38 subjects. Stress Level Ratings in Tinnitus Subjects Figure 4 shows the frequency of -1 Stress ratings provided by 38 subjects; 58% of subjects rated their stress levels as Stress Level Ratings None Mild Moderate Severe Figure 4. The frequency of Stress Level Ratings provided by 38 subjects. We compared the mean PHQ2 scores, Problem Ratings, PainLevel Ratings, Stress Level Ratings, Awareness Percentages and Disturbance Percentages for the two Stress-Level subject

8 Number of Subjects Mean Rating (SD) groups as shown in Figure 5a and Figure 5b. Significant differences were observed only for mean PHQ2 Score (p <.1) and mean Stress Level Rating (p <.1) Stress Level = -6 Stress Level = 7-1 * * PHQ2 Tinn Problem Pain Level Stress Level 12% 11% 1% Figures 5a and Figure 5b. PHQ2 scores, Tinnitus Problem Ratings, PainLevel Ratings, Stress Level Ratings, Awareness Percentages and Disturbance Percentages for the two Pain-Level subject groups. The asterisks denote significant differences between the means. 9% 8% 7% 6% 5% 4% 3% 2% 1% % Awareness % Disturbance % Pain Level Ratings in Tinnitus Subjects Figure 6 shows the frequency of -1 Pain Level ratings provided by 38 subjects; 47% of subjects rated their pain levels as Pain Level Ratings None Mild Moderate Severe Figure 6. The frequency of Stress Level Ratings provided by 38 subjects.

9 We then compared the mean PHQ2 scores, Problem Ratings, PainLevel Ratings, Stress Level Ratings, Awareness Percentages and Disturbance Percentages for the two Pain Level subject groups as shown in Figures 7a and 7b. Significant differences were observed only for PHQ2 Score (p <.5), Pain Level (p <.1) and Awareness Percentage (p <.5) Pain Level = -6 Pain Level = % 1% 2% 1% * * % * PHQ2 Problem Size Pain Level Stress Level Awareness % Disturbance % Figures 7a and 7b. PHQ2 scores, Tinnnitus Problem Ratings, PainLevel Ratings, Stress Level Ratings, Awareness Percentages and Disturbance Percentages for the two Stress-Level subject groups. The asterisks denote significant differences between the means. 9% 8% 7% 6% 5% 4% 3% PHQ2 Scores Benton (211) showed that PHQ2 scores of 3 or higher indicate a need for mental health referral. We divided the subjects into two groups: those who scored -3 on the PHQ2 and those who scored 4-6. Figure 8 shows the frequency of PHQ2 Scores provided by 38 subjects; 5% of subjects PHQ2 scores were 3 or higher.

10 Mean Rating (SD) Number of Subjects PHQ2 Scores Figure 8. The frequency of Stress Level Ratings provided by 38 subjects. We then compared the mean PHQ2 scores, Problem Ratings, PainLevel Ratings, Stress Level Ratings, Awareness Percentages and Disturbance Percentages for the two Stress Level subject groups as shown in Figures 9a and 9b. Significant differences were observed only for PHQ2 Score (p <.1) and Stress Level Rating (p <.1) PHQ2 = -3 PHQ2 = 4-6 * * PHQ2 Problem Tinn Problem Size Pain Level Stress Level 12% 11% 1% Figures 9a and 9b. PHQ2 scores, Tinnitus Problem Ratings, Pain Level Ratings, Stress Level Ratings, Awareness Percentages and Disturbance Percentages for the two PHQ2-Score subject groups. The asterisks denote significant differences between the means. 9% 8% 7% 6% 5% 4% 3% 2% 1% % Awareness % Disturbance %

11 Correlations Table 2. Finally, we performed simple correlations among the various measures as shown in Awareness % Disturbance % Problem % Pain Level Stress Level PHQ ** ** Awareness %.475**.677**.47*.219 Disturbance %.521** Problem %.455*.421** Pain Level.332 BOLD correlations were significant: ** p <.1, * p <.5 Table 2. Correlations among the various measured obtained for 38 tinnitus subjects. Significance levels are noted. As noted, significant correlations were found among the various measures, most of which were substantial. The key relationship findings were: 1. PHQ2 score (mental health screening measure) was significantly correlated to both Tinnitus Problem and Stress Level Rating. 2. Tinnitus Awareness Percentage was significantly correlated to Pain Level Rating. 3. Tinnitus Problem Rating was significantly correlated to both Pain Level Rating and Stress Level Rating. 4. Pain Level Rating and Stress Level Rating were not significantly correlated.

12 Discussion and Conclusions Because there are significant relationships between chronic pain and mental health and between stress and mental health, and because of the strong bi-directional relationship between mental health and tinnitus, we reasoned that both chronic pain and stress also may be related to tinnitus-related distress and/or perceived tinnitus severity. The current findings reveal significant relationships only between Pain Level Ratings and different measures of tinnitus-related distress. Pain Level Ratings were significantly correlated to Tinnitus Problem Ratings and to Tinnitus Awareness Percentages. Stress Level Ratings were significantly correlated only to PHQ2 scores but not to any measure of tinnitus-related distress. Table 3 compares the pain and stress findings reported here for tinnitus subjects to those reported by other researchers studying the general population. The current findings indicate that more tinnitus subjects report severe levels of pain and stress and greater average stress levels than the general population Percentage Reporting Severe Pain Levels Nat l Center Health Stats 21-3% Blyth et al (21) 17-2% Breivik et al (26) 34% Johannes (21) 32% Benton (215) 47% Altaf et al (214) 7-1% Benton (215) 58% Average Stress Level (-1 Scale) APA (214) 4.9 Benton (215) 6.5 Percentage of Subjects Reporting Severe Pain Levels Table 3. Comparison of the current findings regarding pain and stress in tinnitus subjects to those of other researchers studying pain and stress in the general population.

13 The pain reported by tinnitus subjects may be expected to have a substantial impact on the success of any tinnitus management protocol. Pain is a form of physiological stress (Middleton, 23). High stress levels reduce coping skills which, in turn, may be expected to affect the tinnitus subject s ability to manage his or her tinnitus. Chapman et al (28) suggested a systems view of pain in which physical injury, or wounding, generates a complex stress response that extends beyond the nervous system and contributes to the experience of pain. Pain can cause stress, and stress can then exacerbate pain. For example, pain can preclude a normal social life resulting in social isolation and related family problems. Pain-related anxiety can result in negative or catastrophic (worst-case scenario) thinking which may interfere with the provision of social and medical support. The audiologist must be cognizant of pain and stress so as to be able to facilitate, rather than hinder, tinnitus management through proper referrals and through support.

14 Appendix A. Questionnaire completed by 38 tinnitus subjects. Date: Name: Last 4: Over the past two weeks, how many days have you been bothered by: Not at all Several days Over half the days Nearly every day Little Interest or pleasure in doing things Feeling down, depressed or hopeless Thoughts that you would be better off dead, or of hurting yourself in some way. YES NO Over the past two weeks, what percentage of time that you were awake did you hear or were aware of your tinnitus? % Over the past two weeks, what percentage of the time that you heard or were aware of your tinnitus did it really bother you? % Many people try to do something to make themselves feel better when their tinnitus is bothersome. How confident are you that you can do something to feel better when your tinnitus is bothering you? Not at all confident Over the past two weeks, how big a problem has your tinnitus been? Totally confident Not a problem at all As big a problem as you can imagine

15 Do you have a Bedside Sound Machine? YES NO If you DO have a Sound Machine, how many times per week do you use it? If you DO have a Sound Machine, how helpful is it when you use it to help you sleep? Not helpful at all Do you wear hearing aids? YES NO If you DO wear hearing aids, how many hours per day do you use them? If you DO wear hearing aids, how much relief do they provide from your tinnitus? No relief at all As helpful as you can imagine Complete relief Do you experience chronic pain? YES NO If you DO experience chronic pain, how severe is your pain? Not severe As severe as at all you can imagine How would your rate your average stress level? No stress at all As much stress as you can imagine Because tinnitus cannot be cured, people with tinnitus have to make an effort to do things to make their tinnitus less bothersome. How motivated are you to learn new things to make your tinnitus less bothersome? Not motivated at all As motivated as you can imagine How motivated are you to make an effort to actually do these new things to make your tinnitus less bothersome? Not motivated at all As motivated as you can imagine