Correlation between the Degree of Hearing Loss and the Levels of Anxiety and Depression in Patients with Tinnitus

Objectives: This study aimed to explore the correlation between the degree of hearing loss (HL) and the degrees of anxiety and depression in patients with tinnitus. Materials and Methods: This retrospective study involved the use of basic clinical data from 600 enrolled patients with tinnitus who visited the otolaryngology clinic in Affiliated Jinhua Hospital, Zhejiang University School of Medicine from April 2020 to June 2022. The tinnitus handicap inventory (THI) scale was used to assess the tinnitus status among the participants. The pure tone audiometry (PTA) test was used to conduct audiological assessments for all patients to determine their hearing condition. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to assess the levels of anxiety and depression among the participants, respectively. The correlation between the HL and anxiety/depression scores from the questionnaires was tested through Pearson correlation analysis. Results: Among the 600 enrolled patients with tinnitus, most patients had mild-to-moderate degree of tinnitus, accounting for 248 cases (41.3%) and 179 cases (29.8%), respectively. PTA results showed that a large proportion of patients with tinnitus were accompanied with HL (467 cases, 77.8%). Among them, patients with mild HL accounted for the largest proportion with a total of 241 cases (40.2%). Based on the results of SAS and SDS test, almost half of the patients had symptoms of anxiety and depression, accounting for 52.3% (314 cases) and 48.8% (293 cases), respectively. Similarly, patients with mild anxiety and depression occupy the largest proportion, accounting for 35.8% (215 cases) and 23% (138 cases), respectively. Pearson correlation analysis showed that the degree of HL was closely related to THI/SAS/SDS scores (P < 0.001). Conclusion: These findings indicate a strong positive correlation between the degree of HL and anxiety/depression scores in patients with tinnitus.

Keywords: Tinnitus, Hearing loss, Anxiety, Depression, Self-rating anxiety scale, Self-rating depression scale

How to cite this article:
Zhang L, Du H, You H. Correlation between the Degree of Hearing Loss and the Levels of Anxiety and Depression in Patients with Tinnitus. Noise Health 2023;25:195-201
Introduction

Tinnitus is a widely known heterogenous disease, which is specifically defined as a patient producing an illusory sound perception in the absence of a corresponding external sound source.[1],[2] It is mainly classified into subjective tinnitus and objective tinnitus. The former is only perceived by the patients and is the most widespread type of tinnitus. Besides, the examiner can hear objective tinnitus, and the patient can perceive objective tinnitus.[3] In a 35-year demographic study among adults, the global incidence of tinnitus varies from 5.1 to 42.7%, and it increases with noise sensitivity and age.[4] In China, the incidence rate of tinnitus increased obviously over the age of 50 years and stabilizes at about 32% over the age of 70 years.[5] Tinnitus is thought to be caused by auditory and somatosensory dysfunction. It has been hypothesized that the imbalance can result from cochlear lesions caused by hearing loss (HL).[6],[7] HL may form the basis for the formation of tinnitus.[7] Therefore, HL can be considered as a risk factor for tinnitus.[8]

Approximately 90% of tinnitus cases occur with underlying HL.[9] However, some patients with tinnitus have normal hearing by conventional audiometry, and no subjective HL or worsening of HL occurs when new tinnitus occurs.[10] Approximately 85 to 96% of patients with tinnitus have varying degrees of HL. These symptoms caused by tinnitus can seriously affect the daily life of patients.[11]

Approximately 20% of tinnitus cases are severely debilitating, making it difficult to perform daily activities and causing inconvenience to patients in their daily life.[4] Tinnitus and mood disorders have a specific association.[12] Patients with tinnitus as their main symptom may develop mental comorbidities such as anxiety and depression. In the previous studies, depression and anxiety have been identified as the predictive factor for the chronic painful tinnitus.[13] Previous research has also explored the relationship between the pain of tinnitus and depressive symptoms and shown a significant correlation.[14] Besides, anxiety and depression also result in a lower quality of life for patients.[15] The anxiety prevalence rate of tinnitus patients is 24 to 42.1%, and the anxiety prevalence rate of the general population is 7.3%.[16] In a previous study, patients with tinnitus had an apparently higher prevalence rate of depression than the participants without tinnitus.[7]

Limited studies have focused on the correlation between the degree of hearing impairment and the degree of anxiety and depression in patients with tinnitus. In the present study, the tinnitus handicap inventory (THI) scale was used to detect the tinnitus scores of patients with tinnitus. Pure tone audiometry (PTA) test was used to detect the degree of HL in patients with tinnitus. Self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to assess patients’ anxiety and depression scores. The association between HL and symptoms of psychiatric disorders was also explored to provide supplement to the literature. In addition, it can provide a reference for doctors to improve patients’ anxiety and depression from the perspective of improving their hearing.

Materials and Methods

This retrospective study included 600 patients with tinnitus as a primary complaint who visited our otolaryngology clinic during April 2020 to June 2022. The formula for calculating sample size is n = (Z2 × σ2)/d2, where Z is the confidence interval, n is the sample size, d is the sampling error range, and σ is the standard deviation, usually taken as 0.5. The inclusion criteria are as follows: (1) tinnitus as the primary complaint of patients, with or without various types of HL; (2) patients experiencing subjective tinnitus; (3) >18 and <65 years old[17]; (4) patients having good communication skill; (5) written informed consent signed by patients and their families; and (6) patients with complete clinical data. The exclusion criteria are as follows: (1) patients who could not cooperate with audiological and tinnitus examination normally; (2) severe mental diseases or undergoing anti-anxiety or depression treatment; (3) pulsatile tinnitus, somatosounds, or objective tinnitus; (4) pregnant and lactating women; (5) auditory nerve or traumatic brain injury and other organic lesions; (6) patients with incomplete clinical data; and (7) patients with the incomplete clinical data. All patients were informed and signed informed consent for this study. This study was approved by the

Ethics Committee of the Hospital

The general data of patients in each group were collected, including gender, age, tinnitus side, duration of tinnitus, and degree of the anxiety and depression. All patients completed audiological assessment and Chinese version scales including the THI, SAS, and SDS test. Based on whether the patient has experienced HL, the participants were divided into two groups, namely, the normal hearing (control) and HL group. Next, according to the degree of the HL, the HL group was further divided into four subgroups, namely, the mild HL (MHL) subgroup, moderate HL (Mod HL) subgroup, severe HL (SHL) subgroup, and profound HL (PHL) subgroup.

Measurement of Tinnitus

All patients accepted the THI test, which quantifies the influence of tinnitus on daily life through score and determined the severity. The study was conducted using the Chinese–Mandarin type tinnitus disability evaluation scale (THI-CM).[18] The THI scale was composed of three subscales with the aims of evaluating the functional, emotional, and catastrophic effects of tinnitus.[19] It includes 25 questions for 100 points in total. Each question has three choices, namely, Yes (4 points), Occasionally (2 points), and No (0 points). Patients were allowed to make their choice based on their own situation. The severity of tinnitus was divided into five grades according to the following THI scores: slight (0–16 points), mild (18–36 points), moderate (38–56 points), severe (58–76 points), and catastrophic (78–100 points).

Audiologic Assessments

The PTA test was used to conduct audiological assessments for all patients by using the pure tone audiometer (AD104, Melison Medical Instrument Co Ltd, Guangzhou City, Guangdong Province, China). The participants accepted tests in the sound-attenuating room and needed to stay awake during the tests. The average pure-tone hearing threshold is the arithmetic mean of 0.5, 1, 2, and 4 Hz hearing thresholds. The hearing threshold of the right side was tested to calculate the pure-tone threshold in bilateral tinnitus patients. Normal hearing was defined as a constant frequency audiometry threshold <25 decibels (dB). HL degree was classified according to the revised criteria of the World Health Organization (WHO) as follows[20]: normal (0–25 dB), mild (26–40 dB), moderate (41–60 dB), severe (61–80 dB), and profound (>80 dB). Based on the degree of HL, the patients were divided into four groups, namely, the MHL, Mod HL, SHL, and PHL.

Assessment of Anxiety and Depression

The SAS developed by Zung[21] was used to assess an individual’s anxiety degree in the last week. The SAS consisted of 20 projects, each divided into four levels. One point represents “no or very little time,” while four points means “most or all of the time.” The SAS is frequently used because of its reliability and validity.[22] The Cronbach’s alpha between items was 0.820.[23] The SAS standard score is the total score of each item multiplied by 1.25. The SAS standard score ≥50 represents anxiety state. Higher scores indicate more severe anxiety. Grading was based on the following SAS scores: mild anxiety level (50–59 points), moderate anxiety level (60–69 points), and severe anxiety level (≥70 points).

SDS test was conducted to assess an individual’s depressive behavior over the last week.[24] The SDS consisted of 20 items, and each item was scored at four levels. One point means “no or very little time,” while four points means “most or all of the time.” The Cronbach’s alpha between items was 0.840.[23] The SDS standard score is the total score of each item multiplied by 1.25. The SDS standard score <53 represents no depression. Higher scores indicate more severe depression. Grading was based on the following SDS scores: mild depression level (53–62 points), moderate anxiety level (63–72 points), and severe depression level (72 points).

For tinnitus and HL detection, the testers should be skilled in operating the detection equipment, master the detection method, operate according to the standard operation method, and accurately record the test results. For the completion of SAS and SDS scales, testers should make patients fully understand the scoring rules of all scales and the specific meaning of each item, and make patients give true answers in the test process, so that the measurement results are authentic and credible.

Statistical Analysis

SPSS 23.0 statistical software (IBM Corp, Armonk, NY, USA) was utilized to analyses the included participants’ clinical data (age). [Figure 1] to [Figure 3] were made with Excel 2016 (Microsoft, DC, USA). The correction between HL and anxiety/depression scores from the questionnaires were tested using Pearson correlation analysis. Continuous variables are presented as mean ± standard deviation (SD), while categorical variables are presented as number (n) and percentage (%).

Results

Patient Characteristics

[Table 1] presents the patients’ general characteristics. Among the 600 participants, 245 were female (40.8%). The patient’s age is between 21 and 65 years with an average age of 49.96 ± 10.11 years. Audiologic assessments results, the THI score, SAS, and SDS score classification were obtained.

Comparison of Tinnitus Status in Patients among Groups with Different Degrees of Hearing Loss

Based on the data, [Figure 1] shows the measurement results of tinnitus through the THI [Figure 1]. The results showed that the THI rating of tinnitus in the normal group was better than the other four hearing impairment groups (MHL, Mod HL, SHL, PHL group). In the normal group, 131 patients (98.5%) were classified under slight THI, and no patients were classified under severe or catastrophic THI. The THI grading of tinnitus also differed among patients in different HL groups. In the MHL group, 232 patients were classified under mild THI, accounting for 96.3%. A large percentage of patients in the Mod HL group had moderate THI (115 cases, 88.5%), 46 cases in the SHL group had moderate THI (61.3%), and 13 cases in the PHL group had moderate THI (61.9%). In the SHL and PHL groups, more patients with SHL experienced severe tinnitus, as known from THI results.

Figure 1 Comparison of tinnitus status in each hearing loss (HL) groups. HL = hearing loss, PHL = profound HL, SHL = severe HL.

Click here to view

Comparison of Self-rating Anxiety Scale Status in Patients among Groups with Varying Degrees of Hearing Loss

[Figure 2] shows the analysis of the SAS scores of each group. In the control group, 131 patients (98.5%) had normal SAS grade and did not feel anxiety. In the MHL group, the SAS grades of normal and MHL groups were the highest, including 154 (63.9%) and 87 (36.1%) cases, respectively. Neither the control group nor the MHL group involved moderate and severe patients with SAS grading. In the Mod HL group, the SAS grade was mainly mild, accounting for 96.2% (125 cases). In the SHL and PHL groups, the highest number of cases were classified as moderate by SAS, involving 69 (92%) and 14 cases (66.7%), respectively, and no patients were classified as normal based on SAS. Hence, in the present study, the SAS scores increased with the degree of HL in patients with tinnitus.

Figure 2 Comparison of patients in different hearing loss (HL) groups and control group in terms of self-rating anxiety scale (SAS). HL = hearing loss, PHL = profound HL, SHL = severe HL.

Click here to view

Comparison of Self-rating Depression Scale Status in Patients among Groups with Different Degrees of Hearing Loss

The SDS scores of each group were analyzed to observe the depression in different HL groups. As shown in [Figure 3], in the control group, 131 patients (98.5%) had normal SDS grades. In the MHL group, the number of patients with SDS grade of normal was the largest, accounting for 73% (176 cases), followed by mild cases (64 cases, 26.6%). In the Mod HL group, the SDS grade was mainly mild and moderate, including 73 cases (56.2%) and 57 cases (43.8%), respectively. In both the SHL and PHL groups, patients had moderate and severe SDS grades, and no normal and mild cases were recorded. In the SHL group, the SDS grade was moderate in 57 cases, accounting for a large proportion of 76%. In the PHL group, 12 patients (57.1%) had moderate SDS, and 9 patients (42.9%) had severe SDS. Similar to the SAS score, the more severe the HL of patients with tinnitus, the more severe the depression of patients.

Figure 3 Comparison of patients in different hearing loss (HL) groups and control group in terms of self-rating depression scale (SDS). HL = hearing loss, PHL = profound HL, SHL = severe HL.

Click here to view

Relationships between Hearing Loss Degree and Anxiety/Depression/Tinnitus Levels

PTA results reflected the HL status. Normal hearing is defined as a constant frequency audiometry threshold <25 dB, while values >25 dB indicate that different HL degrees occur. As shown in [Table 2], the Pearson correlation analysis exhibited a strong correlation between HL degree and anxiety/depression levels and was remarkably associated with HL and THI scores (all P values <0.001). Based on the scatter plot, the more severe the HL, the higher the SAS and SDS scores, indicating a positive correlation between HL and the degree of anxiety and depression [Figure 4] and [Figure 5].

Table 2 Results of Pearson Correlation Analysis of the Hearing Loss Degree and Self-rating Anxiety Scale/Self-rating Depression/Tinnitus Handicap Inventory Scores.

Click here to view

Figure 4 Correlation between the hearing loss status and anxiety degree. PTA = pure tone audiometry, SAS = self-rating anxiety scale.

Click here to view

Figure 5 Correlation between the hearing loss status and depression degree. PTA = pure tone audiometry, SDS = self-rating depression scale.

Click here to view

Discussion

This study aimed to explore the correlation of anxiety, depression, and hearing impairment in patients with tinnitus. This study found a positive correlation between the situation of tinnitus and HL among participants. The degree of HL in patients with tinnitus is positively correlated with the anxiety, depression, and tinnitus levels. In the current study, the patients’ general characteristics showed that most of the patients with tinnitus in our hospital have mild-to-moderate tinnitus (71.1%), and most of them experience HL, anxiety, and depression as well. Among the research participants in the tinnitus population, 467 patients had symptoms of HL, accounting for 77.8%. In a recent study among 8539 participants, Hackenberg et al.[7] analyzed the incidence of hearing impairment in patients with tinnitus and those without tinnitus. The incidence of mild-to-severe hearing impairment was 51.4% in tinnitus patients and 2% in those participants without. The incidence of hearing impairment was higher in patients with tinnitus than in those without tinnitus. Compared with this study, all the subjects in the current study experience tinnitus. Hence, the rate of HL in this study increased. Previous studies have reported an association between patients with tinnitus and HL possibly because the risk of HL increases with age.[25],[26],[27] The results of the study showed a strong correlation between THI score and PTA results in patients with tinnitus, which was similar to the previous research results of Waechter,[28] who explored the relationship between hearing status and tinnitus disturbance and found that THI score was positively correlated with the average tinnitus side hearing threshold of 0.5 to 4 kHz. Aazh et al.[29] also discussed the relationship between tinnitus degree and pure tone hearing threshold and found that the increase in tinnitus loudness was related to the deterioration of PTA. In different hearing groups in our study, THI grading also differed, and the more severe the HL, the more severe the THI degree, which was similar to the results of previous studies.

Tinnitus is often accompanied by emotional changes in patients, thus affecting the quality of life of patients. In the current study, SAS was used to quantify the anxiety levels of the patients, and the results showed that 314 patients (52.3%) had anxiety. Belli et al.[30] compared 90 outpatient patients with tinnitus and normal people and observed that 18.9% of patients experience anxiety disorders. The scores of anxiety and depression in patients with tinnitus were significantly higher than those in the normal control group. In addition, the depressive state of patients was quantified based on the SDS, and 293 patients (48.8%) had different degrees of depressive mood. A recent systematic review found that the median prevalence of depression in adults with tinnitus was 33% (quartile range 19–49%).[31] A large study of tinnitus patients quantified the relationship between tinnitus, anxiety, and depression and found that 26.1% of tinnitus participants developed symptoms of anxiety and 25.6% of tinnitus participants developed symptoms of depression.[32] However, a study showed that 52.2% of 1490 people with chronic tinnitus reported depression.[33] The rate of mood disorders in patients with tinnitus in this study was similar to that in the present study. Taken together, anxiety/depression symptoms are associated with patients with tinnitus to varying degrees.[34] Anxiety, depression, and other related symptoms already exist when tinnitus occurs. In turn, physical and emotional exhaustion promote the patient’s perception of tinnitus sound, which negatively affect the processing and experience of tinnitus.[35]

The emotional effects of tinnitus are related to the discomfort associated with HL.[11] The correlation between HL and anxiety and depression was further explored in patients with tinnitus. The distribution of anxiety/depression levels differed across different HL groups. Anxiety/depression levels increased as HL increased. Wang et al. included 393 patients with tinnitus as research objects and found that 19.85% were diagnosed with anxiety, and multiple logistic regression analysis showed that the degree of HL was an independent risk factor for anxiety.[16] Improving the hearing status of patients with HL can enhance the levels of anxiety, depression, and tinnitus annoyance.[36],[37] Based on Pearson correlation analysis, HL can be associated with emotional disorders in the participants, with a strong correlation. Therefore, patients need to improve their lifestyle, change their mental state, relieve emotional changes, and use drugs for tinnitus treatment. This study has certain limitations in terms of sample size and region, and future studies with larger samples and more hospitals are needed to further evaluate the clinical characteristics of tinnitus patients. Our study was a retrospective study, and prospective studies can be carried out in the future for the treatment of HL in patients with tinnitus, such as wearing hearing aids, to explore the improvement of emotional disorders in patients. Accordingly, these results will reveal the correlation between hearing and emotion in patients with tinnitus.

Conclusion

In conclusion, hearing impairment, anxiety, and depression caused by tinnitus cause great distress to patients, thus affecting the quality of life and mental health of tinnitus patients. Based on the results, the degree of HL and anxiety/depression scores have a close positive relationship in patients with tinnitus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.Saeed S, Khan QU. The pathological mechanisms and treatments of tinnitus. Discoveries (Craiova) 2021;9:e137.

2.De Ridder D, Schlee W, Vanneste S et al. Tinnitus and tinnitus disorder: Theoretical and operational definitions (an international multidisciplinary proposal). Prog Brain Res 2021;260:1-25.

3.Al-Lahham S, Nazzal Z, Massarweh A et al. Prevalence and associated risk factors of tinnitus among adult Palestinians: a cross-sectional study. Sci Rep 2022;12:20617.

4.McCormack A, Edmondson-Jones M, Somerset S, Hall D. A systematic review of the reporting of tinnitus prevalence and severity. Hear Res 2016;337:70-9.

5.Zhang D, Xu Q, Caimino C, Baguley DM. The prevalence of tinnitus in China: a systematic review of the literature. J Laryngol Otol 2021;135:3-9.

6.Langguth B, Kreuzer PM, Kleinjung T, De Ridder D. Tinnitus: causes and clinical management. Lancet Neurol 2013;12:920-30.

7.Hackenberg B, Doge J, O’Brien K et al. Tinnitus and its relation to depression, anxiety, and stress-a population-based cohort study. J Clin Med 2023;12:1169.

8.Oosterloo BC, Croll PH, Baatenburg de Jong RJ, Ikram MK, Goedegebure A. Prevalence of tinnitus in an aging population and its relation to age and hearing loss. Otolaryngol Head Neck Surg 2021;164:859-68.

9.Haines RH, Hepburn T, Tan W et al. Effectiveness and cost effectiveness of digital hearing aids in patients with tinnitus and hearing loss: a randomised feasibility trial (THE HUSH Trial). Pilot Feasibility Stud 2022;8:235.

10.Park Y, Shin SH, Byun SW, Lee ZY, Lee HY. Audiological and psychological assessment of tinnitus patients with normal hearing. Front Neurol 2022;13:1102294.

11.Scheffer AR, Mondelli M. Tinnitus and hearing survey: cultural adaptation to Brazilian Portuguese. Braz J Otorhinolaryngol 2021;87:28-34.

12.Mohan A, Leong SL, De Ridder D, Vanneste S. Symptom dimensions to address heterogeneity in tinnitus. Neurosci Biobehav Rev 2022;134:104542.

13.Wallhausser-Franke E, D’Amelio R, Glauner A et al. Transition from acute to chronic tinnitus: predictors for the development of chronic distressing tinnitus. Front Neurol 2017;8:605.

14.Langguth B, Landgrebe M, Kleinjung T, Sand GP, Hajak G. Tinnitus and depression. World J Biol Psychiatry 2011;12:489-500.

15.Molnar A, Mavrogeni P, Tamas L, Maihoub S. Correlation between tinnitus handicap and depression and anxiety scores. Ear Nose Throat J 2022 1455613221139211.

16.Wang S, Cha X, Li F et al. Associations between sleep disorders and anxiety in patients with tinnitus: a cross-sectional study. Front Psychol 2022;13:963148.

17.Goshtasbi K, Abouzari M, Risbud A et al. Tinnitus and subjective hearing loss are more common in migraine: a cross-sectional NHANES analysis. Otol Neurotol 2021;42:1329-33.

18.Meng Z, Zheng Y, Liu S et al. Reliability and validity of the Chinese (Mandarin) tinnitus handicap inventory. Clin Exp Otorhinolaryngol 2012;5:10-6.

19.Newman CW, Jacobson GP, Spitzer JB. Development of the tinnitus handicap inventory. Arch Otolaryngol Head Neck Surg 1996;122:143-8.

20.Ma W, Zhang Y, Li X et al. High-frequency hearing loss is associated with anxiety and brain structural plasticity in older adults. Front Aging Neurosci 2022;14:821537.

21.Zung WW. A rating instrument for anxiety disorders. Psychosomatics 1971;12:371-9.

22.Shi C, Guo Y, Ma H, Zhang M. Psychometric validation of the 14-item perceived stress scale in Chinese medical residents. Curr Psychol 2019; 38:1428-34.

23.Xiao C, Mou C, Zhou X. Effect of mindfulness meditation training on anxiety, depression and sleep quality in perimenopausal women [in Chinese]. Nan Fang Yi Ke Da Xue Bao 2019; 39:998-1002.

24.Zung WW. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63-70.

25.Langguth B, Landgrebe M, Schlee W et al. Different patterns of hearing loss among tinnitus patients: a latent class analysis of a large sample. Front Neurol 2017;8:46.

26.Xiong B, Liu Z, Liu Q et al. Missed hearing loss in tinnitus patients with normal audiograms. Hear Res 2019;384:107826.

27.Panahi R, Jalali MM, Joukar F, Maroufizadeh S, Naghipour M, Mansour-Ghanaei F. Prevalence of tinnitus and its associated factors in the PERSIAN Guilan Cohort Study. Iran J Otorhinolaryngol 2023;35:29-38.

28.Waechter S. Association between hearing status and tinnitus distress. Acta Otolaryngol 2021;141:381-5.

29.Aazh H, Salvi R. The relationship between severity of hearing loss and subjective tinnitus loudness among patients seen in a specialist tinnitus and hyperacusis therapy clinic in UK. J Am Acad Audiol 2019;30:712-9.

30.Belli S, Belli H, Bahcebasi T, Ozcetin A, Alpay E, Ertem U. Assessment of psychopathological aspects and psychiatric comorbidities in patients affected by tinnitus. Eur Arch Otorhinolaryngol 2008;265:279-85.

31.Salazar JW, Meisel K, Smith ER, Quiggle A, McCoy DB, Amans MR. Depression in patients with tinnitus: a systematic review. Otolaryngol Head Neck Surg 2019;161:28-35.

32.Bhatt JM, Bhattacharyya N, Lin HW. Relationships between tinnitus and the prevalence of anxiety and depression. Laryngoscope 2017;127:466-9.

33.Niemann U, Brueggemann P, Boecking B, Mazurek B, Spiliopoulou M. Development and internal validation of a depression severity prediction model for tinnitus patients based on questionnaire responses and socio-demographics. Sci Rep 2020;10:4664.

34.Kumbul YC, Isik U, Kilic F, Sivrice ME, Akin V. Evaluation of anxiety sensitivity, anxiety, depression, and attention deficit hyperactivity disorder in patients with tinnitus. Noise Health 2022;24:13-9.

[Full text] 35.Mazurek B, Böcking B, Dobel C, Rose M, Brüggemann P. Tinnitus and influencing comorbidities. Laryngorhinootologie 2023;102:S50-8.

36.Ketterer MC, Häussler SM, Hildenbrand T et al. Binaural hearing rehabilitation improves speech perception, quality of life, tinnitus distress, and psychological comorbidities. Otol Neurotol 2020;41:e563-74.