By Hashir Aazh
Tinnitus is the sensation of sound without any external sound source. Hyperacusis is intolerance of certain everyday sounds that causes significant distress and impairment in social, occupational, recreational, and other day-to-day activities (Aazh et al, 2016). The sounds may be perceived as uncomfortably loud, unpleasant, frightening, or painful (Tyler et al, 2014).
A recent study suggests that over 60 percent of help-seeking patients with tinnitus and/or hyperacusis reported symptoms of anxiety disorders and/or depression (Aazh and Moore, 2017). It has been reported that adverse childhood experiences (ACE) increase the risk of poor mental health later in life (Anda et al, 2006). These experiences are defined as exposures to different forms of abuse (physical, emotional, and sexual) and family dysfunction (substance abuse, mental illness, mother treated violently, incarcerated household member and parental separation) (Felitti et al, 1998).
Parental separation and poor parental mental health are important forms of ACEs with prevalence of 23.3 percent and 19.4 percent, respectively (Anda et al, 2006; Lee and Chen, 2017). ACEs seem to influence the process in which a health condition leads to development of disability (activity limitations and participation restrictions) (Schussler-Fiorenza Rose et al, 2014). However, no study prior to this trilogy of studies (Aazh et al, 2018a; Aazh et al, 2018b; Aazh et al, 2019) has assessed whether the individuals with a history of parental separation and poor parental mental health in their childhood are at more risk of developing tinnitus and hyperacusis disability.
Trilogy of Studies
In a trilogy of studies conducted at the Tinnitus and Hyperacusis Therapy Specialist Clinic (THTSC) at the Royal Surrey County Hospital, the relationships between parental mental health and parental separation in childhood and the psychological impact of tinnitus/hyperacusis on the individual in their adulthood have been explored.
An international network of researchers from different disciplines collaborated in these studies. The collaborators consisted of Professor Brian C. J. Moore (Department of Experimental Psychology, University of Cambridge, United Kingdom), Professor Ali A. Danesh (Department of Communication Sciences and Disorders, Florida Atlantic University, United States), Dr. Michael Landgrebe (Department of Psychiatry, Psychosomatics and Psychotherapy, kbo Lech-Mangfall-Hospital Agathried, Germany), and Professor Berthold Langguth (Department of Psychiatry and Psychotherapy at the University of Regensburg, Germany) See Figure 1.
The study populations in the studies cited here consist of patients who sought help from their general practitioners concerning their tinnitus and/or hyperacusis and who were referred to an audiology clinic. Therefore, the data reported in these studies may not be generalizable to other populations. However, these data are very relevant to audiology clinics that provide therapy and support for patients with tinnitus and hyperacusis.
The aim of this article is to review the key outcomes of these studies.
What are the relationships among parental separation and parental mental health in childhood and tinnitus and hyperacusis disability in adulthood?
In the first study, the data for consecutive patients who attended the THTSC in the UK over a six-month period were included (n=184) (Aazh et al, 2018b). The average age of the patients was 52.5 years (standard deviation, SD=16.1 years, ranged between 18 and 87 years old). Forty-six percent of the patients were male and 14.7 percent of patients reported that, while they were growing up, their parents were separated or divorced.
There were no significant differences in the Tinnitus Handicap Inventory (THI) (Newman et al, 1996) and Hyperacusis Questionnaire (HQ) (Khalfa et al, 2002) between patients with and without history of parental separation.
The mean THI score was 51 (SD=24) in patients whose parents remained together compared to 43.4 (SD=20.2) in patients whose parents separated or divorced. This difference was not statistically significant (p=0.16). The mean HQ score was 17 (SD=9.9) in patients whose parents remained together compared to 18.3 (SD=11.1) in patients whose parents separated or divorced. This difference was not statistically significant (p=0.74).
About 40.2 percent reported a history of mental health disorders in their parents. The mean THI score was 54.8 (SD=22) in patients whose parents had a mental health illness compared to 45.2 (SD=23.2) in patients whose parents did not have a mental health illness. This difference was statistically significant (p=0.004). The mean HQ score was 20 (SD=9.6) in patients whose parents had a mental health illness compared to 16.1 (SD=10.4) in patients whose parents did not have a mental health illness. This difference was statistically significant (p=0.007).
Regression analysis showed that parental mental health illness did not significantly relate to the risk of tinnitus disability as measured via THI. Odds ratio (OR) adjusted for age and gender was 1.96 (95 percent CI: 0.49, 7.67, p=0.33). However, parental mental health illness is significantly related to the risk of hyperacusis disability as measured via HQ; OR adjusted for age and gender was 2.05 (95 percent CI: 1.09, 3.86, p=0.026).
What is the relationship among parental mental health in childhood and anxiety and depression for patients experiencing tinnitus and/or hyperacusis?
In the second study, the data for 287 consecutive patients who attended the THTSC were analyzed (Aazh et al, 2018a). The average age of the patients was 52.5 years (standard deviation, SD=15.5 years, range from 18 to 87 years). Forty nine percent (141/287) of the patients were male. The associations among anxiety and depression and history of parental mental illness was explored.
Depression was assessed using the Patient Health Questionnaire (PHQ-9; Kroenke et al, 2001), which has nine items. Response options were as follows: not at all, several days, more than half the days, and nearly every day.
Anxiety was assessed using the Generalized Anxiety Disorder Questionnaire (GAD-7; Spitzer et al, 2006), which has seven items. Patients are asked how often during the last two weeks they were bothered by each symptom. Response options were as follows: not at all, several days, more than half the days, and nearly every day.
Parental mental health was assessed using a question adopted from the questionnaire for Adverse Childhood Experiences (ACE) (Felitti et al, 1998; Anda et al, 2006). The question was “While you were growing up during the first 18 years of life, did your parent(s) have depression or mental illness?” (p. 247; Felitti et al, 1998). The response alternatives were “yes” or “no.” The test-retest reliability for this question is moderate (Cohen’s kappa=0.48, standard error=0.052, 95 percent CI=0.37-0.58) (Dube et al, 2004).
Thirty-nine percent of patients responded “yes” to the question about their parents’ mental health. Regression analysis showed that parental mental illness significantly increased the risk of anxiety and depression, with unadjusted ORs of 2.7 (95 percent CI: 1.5-4.9, p=0.001) for the PHQ-9 and 2.6 (95 percent CI: 1.4-4.8, p=0.002) for the GAD-7. However, when the models were adjusted for the effects of age, gender, THI, HQ, ULLs, GAD-7 scores (for the depression model only), and PHQ-9 scores (for the anxiety model only), parental mental health was only significantly associated with depression, with an OR of 2.7 (95 percent CI: 1.08-6.7, p=0.033).
What is the relationship among parental mental illness in childhood with suicidal and self-harm ideations in adults seeking help for their tinnitus and/or hyperacusis?
In the third study, the data for 292 consecutive patients who attended the THTSC was analyzed (Aazh et al, 2019). Patients with a primary complaint of either tinnitus or hyperacusis were included in this study. The average age of the patients was 52.4 years (SD=15.6 years, ranged between 18 and 87 years old). Approximately 49 percent of the patients were male. About 85 percent of the patients were seen by an ear, nose, and throat (ENT) specialist, and 100 percent of the patients were seen by their general practitioner prior to being referred to the THTSC for their tinnitus and/or hyperacusis management.
Some of the patients (15.75 percent) expressed that they had been bothered by suicidal and self-harm ideations within the last two weeks. This is consistent with past studies (Aazh and Moore, 2018). In addition, 38.7 percent of patients reported that, while they were growing up during the first 18 years of life, their parent(s) were suffering from a mental illness.
Logistic regression analysis showed a significant relationship between suicidal and self-harm ideations and the history of parental mental illness after adjusting the model for (1) THI, (2) HQ, (3) GAD-7, (4) PHQ-9, and (5) age and gender. Adjusted OR was 2.5 (95 percent CI: 1.14, 5.6, p=.022).
The only other variable that was significantly related to the risk of suicidal and self-harm ideations was depression, adjusted OR was 7.7 (95 percent CI: 2.6, 26.3, p=.001).
To sum up, clinicians who offer tinnitus and hyperacusis rehabilitation should screen for suicidal and self-harm ideations among patients, especially for those with symptoms of depression and a childhood history of parental mental illness.
Conclusions and Clinical Implications
Poor parental mental health was significantly associated with increased hyperacusis disability as measured through HQ. The stronger links between hyperacusis and mental health illness compared to tinnitus could explain the difference observed in the relations of tinnitus and hyperacusis disability with poor parental mental health.
Parental mental illness in childhood increased the risk of depression by a factor of 2.7 for patients with tinnitus and/or hyperacusis.
Approximately 16 percent of patients who sought help for their tinnitus and/or hyperacusis reported some level of suicidal or self-harm ideations. Audiologists who are involved in tinnitus and hyperacusis should screen for suicidal and self-harm ideations among patients, especially for those with symptoms of depression and a childhood history of parental mental illness.
Our findings warrant a more detailed, more systematic, and prospective investigation of the relationship among the breadth of adverse childhood experiences with tinnitus and hyperacusis disability. If findings can be confirmed by further studies, it should be explored whether psychotherapeutic treatments that specifically address the impact of adverse childhood experiences are useful for reducing the distress caused by tinnitus and /or hyperacusis.
This article is a part of the November/December 2019 Audiology Today issue.
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