Is it the sound or your relationship to it? The role of acceptance in predicting tinnitus impact

Abstract

Tinnitus is an experience of sound in the absence of an appropriate external source. A symptom that can accompany most central or peripheral dysfunctions of the auditory system, tinnitus can lead to significant distress, depression, anxiety, and decreases in life quality. This paper investigated the construct of psychological acceptance in a population of tinnitus patients. First, a cross-sectional study (N = 77) was conducted in which a tinnitus specific acceptance questionnaire was developed. Results showed that a Tinnitus Acceptance Questionnaire (TAQ) generated good internal consistency. A factor solution was derived with two factors: activity engagement and tinnitus supression. Second, a longitudinal study (N = 47) investigated the mediating role of acceptance on the relationship between tinnitus distress at baseline and tinnitus distress, anxiety, life quality, and depression at a 7-month follow-up. The results showed full mediation of activity engagement for depression and life quality at follow-up, partial mediation for tinnitus distress, and no mediation for anxiety. The role of acceptance in the negative impact of tinnitus distress merits further investigation.

Introduction

Tinnitus is defined as the experience of sound(s) in the absence of any appropriate external sound source (Tyler, 2000). In a majority of cases, tinnitus is associated with a hearing loss caused by auditory trauma or aging (Eggermont & Roberts, 2004). Tinnitus patients commonly describe their sounds as a constant ringing, hissing, whistling or buzzing, although many other experiences are reported. Prevalence studies suggest that 10–15% of the general population suffer from tinnitus, and 10–20% of those that do (0.5–3% of the general adult population) have severe tinnitus (Andersson, Baguley, McKenna, & McFerran, 2005).

Severe tinnitus often has a notable impact on life quality. Psychological distress in a variety of forms, such as depression, anxiety, sleep disturbance, and concentration difficulties, are commonly reported along with severe tinnitus (Andersson, 2002).

A variety of medical treatments have been tested for tinnitus. Unless there is a clear medical cause behind the tinnitus such as nerve compression by blood vessels, silence is rarely achieved, and most medical treatments have limited success (Andersson et al., 2005). As a result, various psychological techniques have been developed aimed at reducing the negative impact of tinnitus even when the sound itself persists. Of these cognitive behaviour therapy (CBT) is the best supported. In CBT for tinnitus, treatment is focused on management of tinnitus distress and associated problems (Andersson, 2002). Treatment components in CBT for tinnitus, such as cognitive restructuring and training to focus attention, are designed to increase the patients' control of the maladaptive thoughts and feelings associated with the disorder (Henry & Wilson, 2001). The results of a meta-analysis showed that psychological treatment studies, of which a majority had used a CBT approach, had a good effect on decreasing the distress associated with tinnitus (Cohen's d = .80), whereas the results regarding tinnitus loudness, sleep and depression were less promising (Andersson & Lyttkens, 1999). A recent Cochrane review came to a similar conclusion (Martinez Devesa, Waddell, Perera, & Theodoulou, 2007). Actual mediational analyses are rare, however, and the processes of change that account for the impact of CBT for tinnitus are largely unknown. Furthermore, there is a good deal of room for improvement in the impact of CBT, and thus refinements and alternatives are needed.

Within the behaviour therapy framework considerable progress has been made in recent years by focusing on the patient's relationship to distressing experiences rather than the experiences themselves (Hayes, 2004). A wide variety of acceptance and mindfulness methods have evolved based on this conception that seem to provide a new way forward for many disorders (Hayes, Follette, & Linehan, 2004). To date, this new avenue has not been explored with tinnitus in the published literature, with the exception of a pilot study on the effects of mindfulness meditation (Sadlier, Stephens, & Kennedy, 2008).

Psychological acceptance is a process of actively taking in thoughts, memories, feelings and bodily sensations in a specific situation without having to follow or change them (Hayes, Strosahl, & Wilson, 1999). In many disorders, the attempt to eliminate unwanted private experiences is associated with higher levels of psychopathology (Hayes et al., 1996). These include depression, anxiety, trauma, substance use, general mental health and other problems (see Hayes, Luoma, Bond, Masuda, & Lillis, 2006 for a recent review). Acceptance undermines an unhealthy link between private experiences and overt behaviour, in which distress leads to avoidant or self-focused forms of adjustment that in turn produce additional distress. The therapeutic work with acceptance attempts to change the function rather than the content or frequency of thoughts, feelings and sensations, so that more useful behaviours can occur even in the presence of aversive private experiences (Hayes, Strosahl, et al., 1999). Outcome studies on acceptance-based methods such as Acceptance and Commitment Therapy (ACT: Hayes, Strosahl et al., 1999) not only suggest that these methods apply to a wide range of behavioural health problems, but also that their effects are mediated in part by changes in acceptance and related processes (Hayes et al., 2006).

The picture in behaviour medicine is similar. Chronic pain may be especially relevant to the present topic because as with sound perception in tinnitus, complete elimination of pain is rarely a realistic goal. In chronic pain, acceptance is associated with fewer health care visits and reduced use of analgesic medications (McCracken, Carson, Eccleston, & Keefe, 2004), increased functional level and adjustment (McCracken, 1998, McCracken and Eccleston, 2003) and better mental health (Viane et al., 2003). Both laboratory (Hayes et al., 1999, Masedoa and Esteve, 2006), and clinical studies (Dahl et al., 2004, McCracken et al., 2005) show that acceptance-based treatment methods have a positive impact on pain tolerance and the psychological problems associated with chronic pain.

The role of acceptance in chronic tinnitus has not yet been investigated with the exception of a single correlational study, which found positive correlations between tinnitus distress and the use of any coping strategy (e.g., the more the use of coping the more distressed experienced). Acceptance was the only exception, for which a negative correlation was found (Andersson, Kaldo, Strömgren, & Ström, 2004). Acceptance was however measured with a single item, suggesting the need for a more comprehensive measure of acceptance in tinnitus. Developing such a measure seems especially important given how much acceptance is at odds with previous conceptualizations of tinnitus distress (e.g., Scott et al., 1990, Sirois et al., 2006), and thus the potential for innovation and new directions. The aim of the present studies was to develop a self-report measure of tinnitus specific acceptance and then to investigate its role in the impact of tinnitus on psychological functioning.