# Motivation and emotion/Book/2024/Tinnitus and emotion

* Multimedia presentation (3 min)

## Overview

* Case study
* Figure 1. Tinnitus can greatly affect one's life.
* John is a 20-year-old university student who has been suffering from tinnitus. Every day he has to deal with the constant ringing in his ears that appears randomly throughout the day. The ringing in his ears has greatly affected his studying, as he has a lot of trouble concentrating while listening to the ringing. This has also made him feel gradually more anxious as he struggles with his studies, which has also led to him having trouble sleeping at night. As time goes on, John's mental health greatly deteriorates as he becomes moody and depressed (see Figure 1).
Imagine every day you wake up to the sound of ringing. It would come out of nowhere and last for a while before going away. This happens for the entire day; you hear constantly ringing that just will not disappear for good. As this happens for days, weeks and even months, you begin to feel irritated and moody.
Tinnitus is a perceived sound that does not originate from an external sound source. It is often described as ringing, but people can hear other types of sounds, such as whistling or clicking. Tinnitus is common, prevalent in approximately 14.4% of the adult population and 13.6% of the children and adolescents population, and can occur in both children and adults. However, the prevalence of this condition typically increases with age, with the prevalence of adults aged 18-44 years being 13.7% and adults aged 45-64 years being 23.6% (Hackenberg, O’Brien et al., 2023).
Symptoms of tinnitus vary and may improve or even go away over time, but it can also worsen for some individuals. It is chronic, with symptoms lasting for three months or longer. The causes of tinnitus are unclear, but most people who have it tend to have hearing problems. Although symptoms are not severe enough to cause serious life disruptions, some individuals have reported that it affects their mood. In serious cases, it can cause anxiety or depression (see Figure 2) (Davies et al., 2017).
This chapter examines the effects tinnitus can have on emotional states and its processes. It will explore the possible underlying mechanisms of tinnitus and emotion, as well as the techniques that can be utilised to regulate emotion. Using various theories, the chapter will attempt to explain tinnitus and its correlations with emotion.
* Focus questions:
* What is the relationship between tinnitus and emotional states?
* How does tinnitus affect emotional processing?
* How can tinnitus indirectly influence an individual's life?
* What emotional regulation techniques can help cope with tinnitus?

## Relationship between tinnitus and emotion

A study was conducted with 180 patients who suffered from chronic, subjective tinnitus[factual?]. The results showed that 177 (65%) of the patients had stress symptoms. Of these patients with stress symptoms, 75 (64%) of the patients were in the resistance and exhaustion phase of stress (Ciminelli et al., 2018).
Evidence that tinnitus and stress are correlated with each other is further supported by a study on hair-cortisol and hair-brain-derived neurotrophic factor (BDNF) and the relationship between tinnitus loudness and distress. Both cortisol and BDNF are important stress-related biomarkers, as cortisol is a vital hormone involved in the stress response and BDNF is an important part of neuroprotection and synaptic plasticity. The study found that in patients with chronic tinnitus, higher perceived tinnitus loudness was related to higher hair-cortsiol[spelling?] and lower hair-BDNF. Higher tinnitus-related distress is also related to lower hair-BDNF. This indicates that higher perceived tinnitus loudness and tinnitus distress do significantly increase stress levels and negatively impact neuroplasticity (Basso et al., 2022).
Depression is also a prevalent issue among tinnitus patients. A systematic review examining 28 studies showed that the median prevalence of depression was 33%, with an interquartile range of 19% to 49%. The results indicate that depression is a significant burden for people with tinnitus (Salazar et al., 2019).
Another review examined the correlation between chronic tinnitus and depressive symptoms through 33 studies, with 31 of them showing statistically significant correlations. The results of the analysis revealed that the prevalence of clinically relevant depression ranged from 4.6% to 41.6% (Meijers et al., 2022).
One study looked into how tinnitus and depression, anxiety and stress are related. Using the Gutenberg Health Study (GHS) cohort, 8539 participants were included in the study. The results of the study revealed that compared to participants without tinnitus, participants with tinnitus had a higher prevalence of depression, anxiety and somatic symptom disorders. Among tinnitus participants, 41.0% had somatic symptom disorders, 9.5% had depression and 8.8% had anxiety. Logistic regression results also showed that participants with tinnitus had a higher chance of suffering from depression, anxiety or somatic symptom disorders (Hackenberg, Döge et al., 2023).
Overall, these studies indicate that there is a relationship between tinnitus and emotion. Compared to people not suffering from tinnitus, those who suffer from tinnitus, especially chronic tinnitus, have a higher chance of suffering from stress, depression, anxiety and somatic symptom disorders. A substantial number of people with tinnitus suffer from the above conditions, making it vital to address the problems that tinnitus brings to people’s emotional well-being.

## Underlying mechanisms between tinnitus and emotion

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### Amygdala

The amygdala has been a main part of human functioning due to its role as an emotional response mediator. It may also have interactions with the auditory cortex, hence it is possible that the amygdala is involved in the interplay of tinnitus and emotion, due to the way the amygdala responds to sound stimuli (see Figure 3). One study has suggested that there is a difference in the amygdala’s emotional response for patients with tinnitus. 23 participants were involved in the study, with 12 in the chronic subjective tinnitus group and 11 in the control group. The participants were subjected to a range of evocatively emotional audio clips, graded as unpleasant, neutral or pleasant. The fMRI results of the study showed that the amygdala had a lower response to pleasant and unpleasant sounds in the tinnitus group, which may reflect an internal emotional response modification. This results in habituation to emotionally negative sounds, which would in theory predict a heightened amygdala emotional response in patients with tinnitus. This indicates that the amygdala may have a significant role in the emotional response of tinnitus patients (Davies et al., 2017).

### Stress pathways

The hypothalamus-pituitary-adrenal (HPA) axis is one of the vital neuroendocrine systems in charge of the stress response. Along with the autonomic nervous system (ANS) and the hypothalamus-pituitary-thyroid (HPT) axis, they make up part of the various neural and hormonal pathways involved in stress response. It is suggested that through these three pathways, stress can affect the emotional well-being of tinnitus patients. The thyroxine, cortisol and catecholamines are produced to provide signals to the different brain regions as part of the stress response, which in turn can further increase the severity of the tinnitus due to the distress it brings. This leads to a vicious cycle as tinnitus brings more distress and vice versa (Patil et al., 2023).

### Nucleus accumbens (NAc) and prefrontal cortex

The functional connectivity between the nucleus accumbens and the prefrontal cortex may be part of the underlying mechanism between tinnitus and emotion, especially in terms of tinnitus distress. One study had 105 participants, with 50 of them in the chronic tinnitus group and a control group of 55 people. MRI scanning was employed to observe the participants’ directional connectivity between the NAc and the prefrontal cortex. The results showed that participants with tinnitus displayed abnormal directional connectivity between the NAc and the prefrontal cortex, predominately the orbitofrontal cortex (OFC), inferior frontal gyrus (IFG) and middle frontal gyrus (MFG). Tinnitus handicap questionnaire (THQ) scores also positively correlated with increased directional connectivity from the right MFG to the left NAc and the right NAc to the left MFG. Additionally, the duration of tinnitus positively correlated with the enhanced directional connectivity from the right NAc to the right OFC. This indicates that the NAc and prefrontal cortex do play a significant role in the interplay of tinnitus and emotion. In particular, the directional connectivity of the NAc and the MFG is a vital mechanism as they correlate with tinnitus handicap questionnaire scores, which means that the connectivity may have a role in the issues of tinnitus emotional distress (Xu et al., 2019).
Quiz
The autonomic nervous system is involved in?:
Stress response
Emotional response mediation
Reward response :

## Emotional impacts of tinnitus

Tinnitus can deeply negatively affect a person’s emotions and can lead to severe emotional distress in the long term. Tinnitus patients may have feelings of annoyance due to tinnitus and have their quality of life impacted in various ways. Tinnitus can severely impact their emotional functioning and result in anxiety and depression, however, the experience of distress and impairment varies. Depending on factors like personal disorders, and cognitive problems like catastrophic and dysfunctional thoughts, the emotional distress of the patients can vary (Swain, 2021).
The severity of tinnitus is associated with emotional functioning, with increased severity of tinnitus correlating with decreased emotional functioning. Not only that, patients with tinnitus typically have lower emotional functioning than those without tinnitus. Studies exploring depression discovered that people with chronic depression have a higher level of depressive symptoms compared to control groups. This is also the same for anxiety, with people suffering from chronic tinnitus having significantly higher levels of anxiety. There is also evidence suggesting that people with chronic tinnitus have a higher prevalence of psychological problems, particularly anxiety disorders, depression, obsessive-compulsive disorder and phobias. However, it is not certain that these are emotional impacts directly caused by tinnitus (Trevis et al., 2018).

## Techniques and strategies for tinnitus

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### Cognitive behavioural therapy (CBT)

There are multiple strategies and interventions to help patients with tinnitus with their emotional regulation and to cope with tinnitus symptoms. One method is CBT, a type of psychotherapy that combines both cognitive and behavioural therapy in order to modify cognitive behaviour (see Figure 4). One study looked into the clinical efficacy of CBT for chronic subjective tinnitus patients. The total effect size in the intervention group was significantly higher than the control group and had lower scores in anxiety, depression, hostility, interpersonal sensitivity, phobic anxiety, psychotic somatisation and terror compared to the control group. These results suggest that CBT can be an effective emotional regulation method in reliving the symptoms and distress brought about by tinnitus (Juan et al., 2019).

### Sound therapy

Sound therapy is another effective emotional regulation technique that involves sound production that stimulates the auditory system, causing people with tinnitus to pay attention to that sound instead of their tinnitus. This temporarily reduced the intensity and perception of tinnitus. Although the effectiveness of sound therapy is still in discussion, several studies have indicated that sound therapy does relieve tinnitus symptoms (Saeed & Khan, 2021). In particular, one study revealed that there is a significant correlation between tinnitus patients’ emotional changes during sound therapy sessions and the therapy’s effectiveness. The findings of the study emphasise the considerable impact of emotional responses on the efficacy of sound therapy, since when the patients’ emotions are more aroused, the therapeutic effect is increased (Fang, 2024).

### Tailor-made notched music training (TMNMT)

TMNMT is an acoustic neuromodulation technique where the notched music excludes one-octave width of the frequency band centred at the tinnitus patient’s frequency range. This means that the tinnitus frequency range is not stimulated but the neurons adjacent to that range. Due to lateral inhibition, the neurons apply an inhibitory influence of the ‘notched’ range neurons. One study showed that TMNMT significantly decreases tinnitus loudness and MEG results showed decreased synchrony of neurons in cortical areas, which lowers tinnitus perception (Saeed & Khan, 2021). Another study that included 1031 participants showed results of significant statistical differences in the Hospital Anxiety and Depression Scale (HADS), Tinnitus Handicap Inventory (THI) and Tinnitus Loudness Visual Analog Scale (VAS) between pretherapy and posttherapy. It is further suggested that 1-year duration of the therapy significantly decreases THI and HADS scores, hence it is recommended to go through TMNMT for a long time (Ni et al., 2024). These studies indicate that TMNMT is a promising method to help with emotional regulation and tinnitus symptoms.

## Conclusion

Tinnitus as an auditory phenomenon can become a significant source of emotional distress if it becomes a chronic issue. Various studies have indicated a correlation between tinnitus and emotion, with statistics showing that patients with tinnitus have different emotional responses and a higher prevalence of emotional distress compared to those who do not have tinnitus. Further delving into this relationship unravels the underlying mechanisms of tinnitus, which involve various neural systems, like the amygdala, HPA, ANS, HPT, Nac and the prefrontal cortex. These neural systems' roles and functionality are vital to how tinnitus affects emotion, and vice versa. Due to these mechanisms, tinnitus can significantly impact one’s emotions. Many tinnitus patients have to deal with emotional distress and become more stressed and moody. As chronic tinnitus persists, patients can develop depressive and anxiety symptoms– and in general, have their mental health greatly affected negatively. These emotional disturbances can disrupt everyday life, making it difficult for people with tinnitus to live a functional life. However, there are ways to cope with tinnitus and the emotional disturbances it brings. There are several emotional regulation strategies that tinnitus patients can employ. CBT, sound therapy and TMNMT are all methods that can be used to help patients with tinnitus cope with their symptoms and help manage their emotions. Although tinnitus can cause great emotional distress to those affected by the condition, through using emotional regulation techniques and interventions, people with tinnitus can improve their mental health through the better management of their emotions.