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Psychological aspects of tinnitus : the effects of attentional focus, anxiety and fatigue Leader, Leslie 1986

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PSYCHOLOGICAL ASPECTS OF TINNITUS: THE EFFECTS ATTENTIONAL FOCUS, ANXIETY AND FATIGUE. By LESLIE LEADER A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES Department Of P s y c h o l o g y We accept t h i s t h e s i s as c o n f o r m i n g t o the r e q u i r e d s t a n d a r d . THE UNIVERSITY OF BRITISH COLUMBIA October 1986 © L e s l i e L e a d e r , 1986 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date i i A b s t r a c t T h i s study examined the e f f e c t s of a t t e n t i o n a l f o c u s , a n x i e t y , and f a t i g u e on t i n n i t u s d i s t r e s s , i n t e n s i t y and p i t c h i n a group of 60 a d u l t s w i t h t i n n i t u s . S u b j e c t s were randomly a l l o c a t e d t o one of t h r e e e x p e r i m e n t a l groups or t o a group p e r f o r m i n g a c o n t r o l t a s k . In o r d e r t o p r o v i d e a n a t u r a l i s t i c p a r a l l e l t o the l a b o r a t o r y m a n i p u l a t i o n , s u b j e c t s kept a d i a r y of s i m i l a r v a r i a b l e s f o r one week. The e x p e r i m e n t a l m a n i p u l a t i o n s showed t h a t an i n c r e a s e i n a t t e n t i o n a l f o c u s on t i n n i t u s l e d t o a s i g n i f i c a n t i n c r e a s e i n p e r c e i v e d t i n n i t u s i n t e n s i t y . There was an i n d i c a t i o n t h a t i n c r e a s e d a n x i e t y had a s i m i l a r e f f e c t on t i n n i t u s i n t e n s i t y . I n t e r e s t i n g l y , t i n n i t u s p i t c h was r e l a t i v e l y u n a f f e c t e d by m a n i p u l a t i o n s compared t o t i n n i t u s i n t e n s i t y . N a t u r a l i s t i c d i a r y a n a l y s e s i n d i c a t e d s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s between the mood v a r i a b l e s , bored, a n x i o u s , and f a t i g u e on the one hand and t i n n i t u s d i s t r e s s , i n t e n s i t y and p i t c h on the o t h e r . The s t r o n g e s t c o r r e l a t i o n appeared t o be between t i n n i t u s d i s t r e s s and a n x i e t y . A m u l t i p l e r e g r e s s i o n p r o c e d u r e found t h a t t i n n i t u s d i s t r e s s was p o s i t i v e l y c o r r e l a t e d w i t h t i n n i t u s i n t e n s i t y , age, and c o m p l e x i t y of the t i n n i t u s sound; and n e g a t i v e l y c o r r e l a t e d w i t h d u r a t i o n s i n c e o n s e t . There was a h i g h degree of v a r i a b i l i t y among s u b j e c t s i n range of t i n n i t u s d i s t r e s s and i t s t e m p o r a l p a t t e r n i n g . I m p l i c a t i o n s f o r t i n n i t u s t r e a t m e n t , measurement and a proposed model of t i n n i t u s d i s t r e s s a r e d i s c u s s e d . i i i Table of C o n t e n t s A b s t r a c t i i L i s t of T a b l e s v L i s t of F i g u r e s v i Acknowledgements v i i I INTRODUCTION 1 I I LITERATURE REVIEW 3 A. D e s c r i p t i o n of T i n n i t u s 3 B. D e f i n i t i o n a l I s s u e s 16 C. Measurement of T i n n i t u s 17 D. E p i d e m i o l o g y 25 E. F a c t o r s I n f l u e n c i n g Onset & D i s t r e s s L e v e l s 35 a. P r e d i s p o s i n g f a c t o r s 37 b. R e v e a l i n g f a c t o r s 39 c. E x a c e r b a t i n g f a c t o r s 40 F. Treatment of T i n n i t u s 55 G. C o n c l u s i o n s 73 I I I HYPOTHESES 75 IV METHOD 78 A. S u b j e c t s 78 B. Measurement 79 a. S e l f - R e p o r t Measures 79 b. P h y s i o l o g i c a l Measure 82 C. E x p e r i m e n t a l Procedure 84 a. L a b o r a t o r y Procedure 84 b. Home-Monitoring Procedure 86 V RESULTS 87 A. S u b j e c t s 87 B. Group E q u i v a l e n c e 87 C. M a n i p u l a t i o n Checks 90 a. A t t e n t i o n Focus 90 b. A n x i e t y 95 c. F a t i g u e 98 d. Heart Rate 100 i v T a b l e of C o n t e n t s D. Hypotheses t e s t i n g 105 a. A t t e n t i o n Focus 106 b. A n x i e t y 112 c. F a t i g u e 113 d. T i n n i t u s D i a r y 116 e. Other A n a l y s e s 123 VI DISCUSSION 125 a. E f f e c t s of a t t e n t i o n f o c u s 125 b. E f f e c t s of a n x i e t y 129 c. E f f e c t s of f a t i g u e 133 d. Summary of f i n d i n g s 137 e. A proposed model of t i n n i t u s d i s t r e s s 138 f. I m p l i c a t i o n s of measurement 141 g. I m p l i c a t i o n s of t r e a t m e n t 143 h. F u t u r e r e s e a r c h .145 REFERENCES 147 Appendix A 160 Appendix B 161 Appendix C 162 Appendix D 164 Appendix E 165 Appendix F 166 Appendix G 167 Appendix H 168 Appendix I 169 Appendix J 175 Appendix K 178 Appendix L 182 Appendix M 186 Appendix N 190 Appendix 0 191 Appendix P 192 Appendix Q 1 93 L i s t of T a b l e s v T a b l e 1 Summary of s i d e d n e s s of t i n n i t u s from l i t e r a t u r e 32 Table 2 Demographic c h a r a c t e r i s t i c s of s u b j e c t s 88 Ta b l e 3 M a n i p u l a t i o n check f o r a t t e n t i o n f o c u s ( r e p e a t e d measures MANOVA) 91 Ta b l e 4 C e l l means of dependent v a r i a b l e s 92 Ta b l e 5 M a n i p u l a t i o n check f o r a n x i e t y ( r e p e a t e d measures MANOVA) 97 Ta b l e 6 M a n i p u l a t i o n check f o r f a t i g u e ( r e p e a t e d measures MANOVA) 99 Ta b l e 7 Repeated measures ANOVAs on h e a r t r a t e 103 Ta b l e 8 C e l l means of t i n n i t u s measures 107 Ta b l e 9 Repeated measures MANOVA on t i n n i t u s v a r i a b l e s f o r a t t e n t i o n f o c u s m a n i p u l a t i o n ....108 T a b l e 10 Repeated measures MANOVA on t i n n i t u s v a r i a b l e s f o r a n x i e t y m a n i p u l a t i o n 114 Ta b l e 11 Repeated measures MANOVA on t i n n i t u s v a r i a b l e s f o r f a t i g u e m a n i p u l a i o n 115 Ta b l e 12 C o r r e l a t i o n s between t i n n i t u s v a r i a b l e and mood v a r i a b l e s from t i n n i t u s d i a r y 118 Ta b l e 13 Modal ranges of i n t r a i n d i v i d u a l c o r r e l a t i o n s between t i n n i t u s v a r i a b l e s and mood v a r i a b l e s on t i n n i t u s d i a r y 120 Ta b l e 14 P a r t c o r r e l a t i o n c o e f f i c i e n t s between t i n n i t u s d i s t r e s s and a n x i e t y , f a t i g u e , and boredom ....121 v i L i s t of F i g u r e s F i g u r e 1 Combinations of p r e s e n c e / p e r c e p t i o n i n t e r a c t i o n f o r head-sounds 18 F i g u r e 2 E x p e r i m e n t a l D e s i g n 82 F i g u r e 3 Mean f o c u s v e r i f i c a t i o n over e x p e r i m e n t a l phases 96 F i g u r e 4 Mean h e a r t r a t e over e x p e r i m e n t a l phases 101 F i g u r e 5 Mean t i n n i t u s d i s t r e s s r a t i n g over e x p e r i m e n t a l phases 109 F i g u r e 6 Mean t i n n i t u s i n t e n s i t y r a t i n g over e x p e r i m e n t a l phases 110 F i g u r e 7 Mean t i n n i t u s p i t c h r a t i n g over e x p e r i m e n t a l phases 111 v i i Acknowledgement I am i n d e b t e d t o a number of p e o p l e who have h e l p e d me i n many ways: t o my t h r e e committee members f o r t h e i r g e n e r o s i t y w i t h time and a d v i c e : Ken C r a i g f o r h i s i n d i s p e n s a b l e encouragement and c a r e f u l g u i d a n c e , Jack Rachman f o r h i s r e s o u r c e f u l n e s s and f o r h e l p i n g me t o cut c o m p l e x i t y , Ronnie Lakowski f o r h i s support and u s e f u l comments, t o R a l p h H a k s t i a n , J i m S t e i g e r , and V i r g i n i a Green f o r t h e i r i n v a l u a b l e s t a t i s t i c a l c o n s u l t i n g , t o Jack Vernon Ph.D., Des B e l l M.D., and N e i l L o n g r i d g e M.D. f o r t h e i r e a r l y i n t e r e s t and g e n e r o s i t y w i t h i n f o r m a t i o n and a d v i c e , t o s u b j e c t s ( l a r g e l y members of the Vancouver T i n n i t u s S e l f - H e l p Group) f o r a c t i n g on t h e i r p e r s o n a l commitment t o advance the knowledge of t i n n i t u s , t o L e s l i e McKenzie and D a r y l Zacharko f o r t h e i r h e l p w i t h d a t a -and t e x t - p r o c e s s i n g and t h e i r good n a t u r e d t o l e r a n c e of c r i s e s , and i n e s t i m a b l y t o Eve, my s i n e qua non. 1 I I n t r o d u c t i o n •-. T i n n i t u s i s u s u a l l y c o n s i d e r e d t o be a symptom of an u n d e r l y i n g somatic d i s o r d e r b u t , i n c r e a s i n g l y , e v i d e n c e s u g g e s t s t h a t p s y c h o l o g i c a l f a c t o r s c o n t r i b u t e t o the d i s t r e s s a s s o c i a t e d w i t h t i n n i t u s and i t s s e n s o r y q u a l i t i e s . The proposed r e s e a r c h i n v e s t i g a t e s some of t h e s e p r o c e s s e s . T i n n i t u s may be d e s c r i b e d as i n t e r n a l sound or sounds l o c a l i z e d i n the head and o c c u r r i n g i n the absence of e x t e r n a l a c o u s t i c s t i m u l i . They a r e g e n e r a l l y e x p e r i e n c e d f o r p r o l o n g e d p e r i o d s and can be e x t r e m e l y d i s t r e s s i n g . A broad range of i n t e r v e n t i o n s t r a t e g i e s has been a t t e m p t e d , w i t h none u n i v e r s a l l y s u c c e s s f u l (McFadden, 1982). M e d i c a l t r e a t m e n t can o c c a s i o n a l l y s i l e n c e the t i n n i t u s , b u t , f o r the m a j o r i t y of c a s e s , t h e r e i s no known t r e a t m e n t t o a c h i e v e t h i s . In c e r t a i n c a ses the masker, a p r o s t h e t i c d e v i c e which b r o a d c a s t s a masking sound t o the e a r , has proven p a l l i a t i v e (Vernon & S c h l e u n i n g , 1978; Stephens & C o r c o r a n , 1985) b u t , f o r the most p a r t , t i n n i t e u r s are a d v i s e d t o " l i v e w i t h i t . " A l t h o u g h most a d j u s t t o the symptom over t i m e , i t can be d i s t r e s s i n g i n v a r y i n g d e g r e e s . U n t i l r e c e n t l y , j u d g i n g by the number of p s y c h o l o g i c a l p u b l i c a t i o n s d e a l i n g w i t h t i n n i t u s , t h e r e has not been a g r e a t d e a l of r e s e a r c h or c l i n i c a l i n t e r e s t i n the p s y c h o l o g i c a l l y based t r e a t m e n t s f o r d i s t r e s s from t i n n i t u s . In the p a s t few y e a r s , however, t h e r e has been a growing i n t e r e s t among p s y c h o l o g i s t s i n t h i s problem. T h i s might be due t o the upsurge 2 of i n t e r e s t i n m e d i c a l p s y c h o l o g y . I t s w i d e n i n g scope has now i n c l u d e d t i n n i t u s and i s r e f l e c t e d both i n t h e o r e t i c a l r e s e a r c h (e.g. H a l l a m , Rachman, and H i n c h c l i f f e , 1984) and t r e a t m e n t r e s e a r c h ( e.g. S c o t t , L i n d b e r g , L y t t k e n s , & M e l i n , 1985). S i n c e i t i s u n l i k e l y t h a t a cu r e f o r t i n n i t u s i s imminent ( i f t h i s means s i l e n c i n g the t i n n i t u s sound), i t seems t i m e l y t o conduct r e s e a r c h t o d i s c o v e r which f a c t o r s e x a c e r b a t e the d i s t r e s s t h a t can f o l l o w t i n n i t u s o n s e t . A good s t a r t i n g p o i n t f o r t h i s r e s e a r c h might be the s y s t e m a t i c i n v e s t i g a t i o n of f a c t o r s which have been found t o i n f l u e n c e p a i n p e r c e p t i o n and which might be c o n c e p t u a l l y g e n e r a l i z e d t o t i n n i t u s . A second h e u r i s t i c would be t o t e s t e x p e r i m e n t a l l y some of the p e r s o n a l hypotheses t i n n i t e u r s have about which f a c t o r s e x a c e r b a t e t h e i r t i n n i t u s . T h i s t h e s i s w i l l pursue e x p e r i m e n t a l l y c e r t a i n a s p e c t s of th e s e broad l e a d s . In t h i s i n v e s t i g a t i o n t i n n i t e u r s w i l l be exposed e x p e r i m e n t a l l y t o c o n d i t i o n s which s y s t e m a t i c a l l y induce f a t i g u e and a n x i e t y ; and which f o c u s a t t e n t i o n on and away from the t i n n i t u s sound. The purpose of t h i s t h e s i s i s t o i n v e s t i g a t e whether t h e s e f a c t o r s e x a c e r b a t e d i s t r e s s f e l t from t i n n i t u s . The u l t i m a t e u s e f u l n e s s of t h i s r e s e a r c h might be t o det e r m i n e whether t h e s e f a c t o r s s h o u l d be i n c l u d e d i n a p s y c h o l o g i c a l t r e a t m e n t p r o t o c o l t o a l l e v i a t e t h i s d i s t r e s s . 3 I I L i t e r a t u r e Review A. D e s c r i p t i o n of t i n n i t u s "I a l s o e x p e r i e n c e d a s t r a n g e a c o u s t i c h a l l u c i n a t i o n , c o n t i n u o u s l y h e a r i n g - p r o b a b l y because of nervous o v e r - e x e r t i o n a duet of two male v o i c e s i n D-major w i t h a deep organ sound, which would s t o p o n l y when I put my head out of the window, but i m m e d i a t e l y s t a r t e d a g a i n when I s a t down." (Lowenbach, 1943, q u o t i n g from a l e t t e r w r i t t e n i n 1862 by the Czech composer, B e d r i c h Smetana). N i n e t e e n y e a r s l a t e r Smetana w r o t e : "The d r o n i n g and v i o l e n t b u z z i n g i n my head, as though I were s t a n d i n g under a huge w a t e r f a l l , remained w i t h me, and has gone on n i g h t and day w i t h o u t i n t e r r u p t i o n , more s t r o n g l y when my emotions a r e s t i r r e d up, and weaker on days when I am i n a q u i e t a f f e c t . The b u z z i n g grows s t r o n g e r when I am composing." (Lowenbach, 1943). Smetana's v i v i d d e s c r i p t i o n of h i s t i n n i t u s conveys the c o m p l e x i t y of the sounds heard by some t i n n i t e u r s . I n i t i a l l y i n 1862 he d e s c r i b e d the two m u s i c a l sounds superimposed on a l o w e r , o r g a n - l i k e tone. N i n e t e e n y e a r s l a t e r t h e s e became more a b u z z i n g , r u s t l i n g n o i s e . Smetana p r o v i d e d an i n s t a n c e of how v a r i a b l e these sounds can be i n p i t c h , l o u d n e s s , and q u a l i t y . He was a l s o aware of how h i s e m o t i o n a l s t a t e might have i n f l u e n c e d h i s p e r c e p t i o n of t h e i r l o u d n e s s and of how an e n v i r o n m e n t a l f a c t o r and a p o s t u r a l adjustment c o u l d change h i s p e r c e p t i o n of the t i n n i t u s sounds. T i n n i t u s c l e a r l y can be a d i s t u r b i n g symptom and, a l t h o u g h 4 the etymology of the word r e f e r s t o a r i n g i n g t o n e , i t can ta k e many forms, as Smetana g r a p h i c a l l y d e s c r i b e s . T i n n i t u s i s the symptom of h e a r i n g a sound or sounds i n the absence of e x t e r n a l s t i m u l i . By d e s c r i b i n g i t as a symptom, the presence of a c a u s a l p a t h o l o g y i s i m p l i e d . As w i l l be d e s c r i b e d l a t e r , w i t h p r e s e n t knowledge causes a r e r a r e l y i d e n t i f i a b l e so t h a t most c a s e s of t i n n i t u s a re of unknown e t i o l o g y . The purpose of the f o l l o w i n g l i t e r a t u r e r e v i e w i s t o p r o v i d e a background t o the development of the p r e s e n t s t u d y . The emphasis, f o r the most p a r t , i s on the p s y c h o l o g i c a l i m p l i c a t i o n s of r e s e a r c h i n t o t i n n i t u s t h u s f a r . Both the t i n n i t u s and p a i n l i t e r a t u r e s a r e c o v e r e d i n the re v i e w w i t h the aim of i n t e g r a t i n g a s p e c t s of each t o y i e l d i d e a s which may prove h e l p f u l i n i n v e s t i g a t i n g the n a t u r e of t i n n i t u s , d i s t r e s s from t i n n i t u s , and i t s t r e a t m e n t . Range and v a r i a t i o n . There i s a p p a r e n t l y no s i m p l e r e l i a b l e r e l a t i o n s h i p between s e l f - r e p o r t s of t i n n i t u s and i t s p h y s i c a l c h a r a c t e r i s t i c s . Graham and Newby (1967) r e p o r t e d t h a t v e r b a l d e s c r i p t i o n s used by s u b j e c t s t o d e s c r i b e t h e i r t i n n i t u s were u n r e l a t e d t o p i t c h , l o u d n e s s of the t i n n i t u s sound, or t o d i a g n o s t i c c a t e g o r y . In c o n t r a s t t o t h i s Reed (1960) found t h a t the d e s c r i p t i o n s o f f e r e d by t i n n i t e u r s of t h e i r t i n n i t u s c o r r e s p o n d e d w i t h the measured f r e q u e n c y band w i d t h . A l t h o u g h not s t a t i s t i c a l l y v a l i d a t e d , he r e p o r t e d t h a t a broad band t i n n i t u s was most o f t e n d e s c r i b e d as 5 "steam"; a medium band w i d t h as a "buzz"; and narrow band or pure tone t i n n i t u s as a " r i n g " . In Reed's (1960) sample of 200 t i n n i t e u r s , the d i s t r i b u t i o n of the c e n t r a l f r e q u e n c y of the t i n n i t u s sounds had a mode a t between 3 and 4 kHz; about 90% of the f r e q u e n c i e s e f f e c t i v e l y f e l l w i t h i n a range of 0.5 t o 8.5 kHz thus r e p r e s e n t i n g a p o s i t i v e l y skewed d i s t r i b u t i o n w i t h more ca s e s i n the lower f r e q u e n c i e s . Vernon's (1975) sample of 513 t i n n i t e u r s had a d i s t r i b u t i o n of t i n n i t u s f r e q u e n c i e s v e r y s i m i l a r t o Reed's: 21% below 2 kHz, 63% between 2 & 7 kHz & 16% above 7kHz. Thus t i n n i t u s has modal f r e q u e n c i e s i n the range between 2 and 7 or 8 kHz. Reed's ( i 9 6 0 ) d a t a on the d i s t r i b u t i o n of t i n n i t u s f r e q u e n c i e s d i d not c o r r e s p o n d w i t h the d i s t r i b u t i o n o b t a i n e d by Graham & Newby (1967). U n f o r t u n a t e l y , the l a t t e r ' s r e p o r t d i d not p r o v i d e s u f f i c i e n t d e t a i l s of t h e i r f i n d i n g s t o a l l o w c l o s e r i n s p e c t i o n . Many t i n n i t e u r s r e p o r t f l u c t u a t i o n s i n the p i t c h of t i n n i t u s but s y s t e m a t i c r e s e a r c h i n t o t h i s t o p i c i s r a r e . Some v a r i a t i o n has been r e p o r t e d . In a f o u r week l o n g i t u d i n a l study w i t h t h r e e s u b j e c t s whose t i n n i t u s was r e l a t e d t o n o i s e e x posure, i t was found t h a t matched f r e q u e n c i e s v a r i e d by ranges as g r e a t as from 2 t o 5 kHz (Penner, quoted i n McFadden, 1982, p.36). T h i s v a r i a t i o n was a l s o mentioned by Voroba (1979a), who suggested t h a t i t was caused by the method of measurement and i n s t r u m e n t a t i o n r a t h e r than by a f l u c t u a t i o n i n the p i t c h of the t i n n i t u s sound. The wide v a r i a t i o n i n p i t c h e x p e r i e n c e d by a t l e a s t some t i n n i t e u r s and r e p o r t e d i n thes e s t u d i e s suggests t h a t the proce d u r e of a s i n g l e measurement of matched p i t c h 6 might have o n l y l i m i t e d u t i l i t y i n these c a s e s . To summarize, t h i s v a r i a t i o n may be e x p l a i n e d i n two ways: as b e i n g due t o changes i n the p e r c e i v e d sound, or t o i n s u f f i c i e n c i e s i n measurement p r o c e d u r e s . Problems i n measurement w i l l be d e s c r i b e d i n more depth l a t e r . In c o n t r a s t t o the f l u c t u a t i o n r e p o r t e d above, t h e r e have been s t u d i e s which a t t e s t e d t o the r e l a t i v e c o n s t a n c y of the t i n n i t u s sound. In one s t u d y , t e s t - r e t e s t r e l i a b i l i t y over f o u r months was r e p o r t e d t o be h i g h , w i t h r e t e s t s t y p i c a l l y f a l l i n g w i t h i n o n e - s i x t h of an o c t a v e of the f i r s t e s t i m a t e s ( T y l e r & Conrad-Armes, 1980). A l s o M a l a t e s t a , S u t k e r & Adams (1980) i n a s i n g l e - c a s e s t u d y , r e p o r t e d almost complete c o n s i s t e n c y i n the matching of a tone of 6 kHz t o h i s s u b j e c t ' s t i n n i t u s i n each of 220 t r i a l s over a two-month p e r i o d . However, the tone g e n e r a t o r was c a l i b r a t e d i n d i s c r e t e i n t e r v a l s of 1 kHz thus e l i m i n a t i n g the p o s s i b i l i t y of f i n e r d i s c r i m i n a t i o n s and v a r i a t i o n s i n the s e l e c t e d t o n e . Graham & Newby (1967) compared a c o u s t i c c h a r a c t e r i s t i c s of t i n n i t u s sounds a s s o c i a t e d w i t h v a r i o u s known e t i o l o g i e s of h e a r i n g l o s s . They found t h a t the t i n n i t u s p i t c h e s of s e n s o r i n e u r a l and s e n s o r i n e u r a l - c o n d u c t i v e h e a r i n g - l o s s s u b j e c t s were not s i g n i f i c a n t l y d i f f e r e n t . O v e r a l l they had the wide range of 40 Hz t o 7.8 kHz. However a t h i r d group w i t h c o n d u c t i v e h e a r i n g l o s s had a s i g n i f i c a n t l y lower and more r e s t r i c t e d p i t c h range than the o t h e r two groups (.12 t o 1.4 k H z ) . The a u t h o r s suggested t h a t c o n d u c t i v e h e a r i n g l o s s might 7 have a d i f f e r e n t p h y s i o l o g i c a l mechanism of t i n n i t u s p r o d u c t i o n than f o r o t h e r s o u r c e s of the d i s o r d e r . Loudness and p i t c h . Reed (1960) r e p o r t e d t h a t pure-tone and narrow band t i n n i t u s tended t o be p e r c e i v e d as l o u d e r than broad band t i n n i t u s . He a l s o found t h a t lower t i n n i t u s f r e q u e n c i e s tended t o be r e p o r t e d as b e i n g l o u d e r than the h i g h e r f r e q u e n c i e s . The p e r c e i v e d l o u d n e s s of the t i n n i t u s has been r e p e a t e d l y demonstrated t o be of low i n t e n s i t y i n most c a s e s when measured o b j e c t i v e l y . Reed ( i 9 6 0 ) found t h a t 69% of h i s sample matched t h e i r t i n n i t u s t o a tone of 10 dB SL or l e s s and t h a t o n l y 5% needed a tone of more than 30 dB SL. These r e s u l t s have been b r o a d l y c o n f i r m e d by Graham (1960) who found t h a t , whereas 75% matched t o 10 dB SL or l o w e r , o n l y 4% matched t o more than 20 dB SL. Vernon (1975), a f t e r s u r v e y i n g 513 t i n n i t e u r s w i t h s e v e r e t i n n i t u s , r e p o r t e d t h a t the l o u d n e s s was u s u a l l y 5 t o 10 dB SL ( a l t h o u g h i n a few c a s e s i t was 40 dB SL and as h i g h as 70 dB f o r one p a t i e n t ) . Most t i n n i t e u r s t h u s e x p e r i e n c e t i n n i t u s a t a l e v e l w i t h i n 5 t o 10 dB of t h e i r h e a r i n g t h r e s h o l d s and almost a l l w i t h i n 30 t o 40 dB of t h e i r t h r e s h o l d s . I t was l i k e l y t h a t these s t u d i e s s u f f e r e d from a u b i q u i t o u s problem i n l o u d n e s s - m a t c h i n g p r o c e d u r e s . I f the ear t o which the v a r i a b l e tone i s p r e s e n t e d f o r matching t o the i n t e n s i t y of the t i n n i t u s sound s u f f e r s from l o s s of s e n s i t i v i t y , then measurements over the range of the reduced s e n s i t i v i t y would be 8 t o o h i g h . In c o n t r a s t t o t h i s e x p l a n a t i o n i n terms of l o s s of s e n s i t i v i t y , Vernon (1976) has suggested an e x p l a n a t i o n of p o s s i b l e d i s c r e p a n c y i n terms of a r e c r u i t m e n t p r o c e s s . Low t i n n i t u s i n t e n s i t i e s , when s u b j e c t t o the a b n o r m a l l y r a p i d growth of l o u d n e s s c h a r a c t e r i s t i c of e a r s d i s p l a y i n g r e c r u i t m e n t , might sound a b n o r m a l l y l o u d and t h e r e f o r e be more d i s t r e s s i n g than t h e i n t e n s i t y of a matched sound might i n d i c a t e . In one of the few s t u d i e s i n the e a r l i e r t i n n i t u s l i t e r a t u r e u s i n g c o n t r o l groups, Graham & Newby (1967) compared the a c o u s t i c a l c h a r a c t e r i s t i c s of f o u r groups t o t a l l i n g 100 s u b j e c t s . Three of the groups ( s e n s o r i n e u r a l , s e n s o r i n e u r a l -c o n d u c t i v e and c o n d u c t i v e h e a r i n g l o s s groups) c o n s i s t e d of s u b j e c t s who had t i n n i t u s , w i t h the f o u r t h group c o n s i s t i n g of n o r m a l - h e a r i n g , t i n n i t u s - f r e e s u b j e c t s . They found t h a t t h e r e were no s i g n i f i c a n t d i f f e r e n c e s i n r e p o r t e d l o u d n e s s among the t h r e e groups w i t h v a r y i n g e t i o l o g i e s . More than h a l f of the t h e s e s u b j e c t s matched the t i n n i t u s l o u d n e s s t o s t i m u l i 5 dB SL or l e s s above t h r e s h o l d . I f d e c r e a s e d or enhanced s e n s i t i v i t y t o s t i m u l u s l o u d n e s s were s y s t e m a t i c a l l y a s s o c i a t e d w i t h c h a r a c t e r i s t i c s of some or a l l of the h e a r i n g - i m p a i r e d groups, s i g n i f i c a n t group d i f f e r e n c e s might have been found. The f a c t t h a t t h i s was not the case c o u l d be e x p l a i n e d by the absence of c l e a r i n t e r g r o u p d i f f e r e n c e s i n h e a r i n g s e n s i t i v i t i e s . Formby & G j e r d i n g e n (1980) found t h a t t h e r e was s u b s t a n t i a l v a r i a t i o n between t r i a l s i n masking i n t e n s i t i e s ( t y p i c a l l y 15-20 dB but as h i g h as 40 dB) t h a t were n e c e s s a r y t o mask a t i n n i t u s sound on 9 r e p e a t e d t e s t i n g . T h i s c o n f i r m s the g e n e r a l l y - h e l d a s s e r t i o n t h a t t i n n i t u s volume f l u c t u a t e s over time and s u g g e s t s another p o t e n t i a l reason f o r the l a c k of a s s o c i a t i o n found between t i n n i t u s l o u d n e s s and r e p o r t e d d i s t r e s s : the use of s i n g l e e s t i m a t e s of t i n n i t u s l o u d n e s s as d a t a f o r a n a l y s i s . The d i s c r e p a n c y between the lo u d n e s s of t i n n i t u s sounds and the magnitude of r e s u l t i n g d i s t r e s s has l o n g i n t r i g u e d r e s e a r c h e r s i n t h i s f i e l d . A l t h o u g h l o u d e r t i n n i t u s sounds might be expected t o be a s s o c i a t e d w i t h more d i s t r e s s , r e s e a r c h r e p o r t s have g e n e r a l l y not s u p p o r t e d t h i s e x p e c t a t i o n . H a l l a m , Rachman, & H i n c h c l i f f e (1984) compared p a t i e n t s who p r e s e n t e d w i t h t i n n i t u s as the main c o m p l a i n t f o r c o n s u l t a t i o n a t an ENT c l i n i c w i t h those f o r whom t i n n i t u s was secondary t o o t h e r symptoms such as d e a f n e s s or d i z z i n e s s . They found no d i f f e r e n c e s between t i n n i t u s l o u d n e s s e s t i m a t e s (measured by c o n t r a l a t e r a l l o u d n e s s b a l a n c e ) f o r the groups, nor f o r sound p r e s s u r e l e v e l s r e q u i r e d t o mask the t i n n i t u s . T h i s suggested t h a t the c o m p l a i n e r s , a l t h o u g h more d i s t r e s s e d by t h e i r symptoms, d i d not have more i n t e n s e t i n n i t u s as measured by thes e t e c h n i q u e s . I t was p o s s i b l e t h a t o t h e r c h a r a c t e r i s t i c s of the t i n n i t u s sound or of the t i n n i t e u r s were r e s p o n s i b l e f o r the d i f f e r e n t i a l i n d i s t r e s s found i n t i n n i t e u r s , the a u t h o r s s u g g e s t e d . 10 O t o a c o u s t i c e m i s s i o n s . A phenomenon r e l a t e d t o t i n n i t u s but d i s t i n c t from i t i n i m p o r t a n t r e s p e c t s i s the o t o a c o u s t i c e m i s s i o n (OAE). An OAE i s d e t e c t a b l e a c o u s t i c energy e m i t t e d by an e a r . In some c a s e s i t can be heard by a l i s t e n e r p l a c i n g an ear on the e m i t t i n g e a r , but i n o t h e r c a s e s i n s t r u m e n t s a r e needed t o a m p l i f y the sound b e f o r e i t can be d e t e c t e d . The person e m i t t i n g the OAE may or may not be a b l e t o hear i t . The t e c h n o l o g y f o r d e t e c t i n g a c o u s t i c energy i n the e x t e r n a l a u d i t o r y meatus was d e v e l o p e d r e c e n t l y (Kemp and Chum, 1980; W i l s o n , 1979, 1980; W i l s o n & S u t t o n , 1981; & Zurek, 1981). I t was found, u s i n g a m i n i a t u r i z e d microphone, t h a t i t was not unusual f o r a normal ear t o have a spontaneous OAE a t one or more f r e q u e n c i e s which an examiner u s i n g o n l y a s t e t h o s c o p e would not d e t e c t . C e r t a i n a t t r i b u t e s of OAEs have been d e s c r i b e d but a t t h i s s tage t h e s e d e s c r i p t i o n s must remain t e n t a t i v e due t o the s m a l l sample s i z e s used i n the r e s e a r c h , presumably as a r e s u l t of the r a r i t y of OAEs. I t has been found t h a t OAEs, r a t h e r than b e i n g d e s c r i b e d as pure t o n e s , were r a t h e r l i k e bands of n o i s e (Kemp, 1981; W i l s o n & S u t t o n , 1981; Zurek, 1981), 1.2 t o 4.7 kHz i n w i d t h (Kemp, 1981). Volumes of OAEs are from about 0 t o 30 dB SPL. They a r e g e n e r a l l y b e l i e v e d t o be c o c h l e a r i n o r i g i n (McFadden, 1982). T y l e r & Conrad-Armes (1980) i n v e s t i g a t e d 20 n o r m a l - h e a r i n g 11 s u b j e c t s and found t h a t w h i l e f i v e had OAEs, none was a u d i b l e t o i t s owner. S u t t o n & W i l s o n (1981) t e s t e d 16 e a r s from n i n e t i n n i t e u r s and d e t e c t e d OAEs from seven e a r s . A major f r e q u e n c y component of t h e s e OAEs c o r r e s p o n d e d w i t h a t i n n i t u s f r e q u e n c y i n f o u r i n s t a n c e s ; t e n e a r s w i t h t i n n i t u s produced no d e t e c t a b l e OAEs; and i n two e a r s w i t h OAEs no t i n n i t u s was p e r c e i v e d . Thus, i t seems as though a l l c o m b i n a t i o n s of the presence or absence of t i n n i t u s and the presence or absence of OAE's a r e p o s s i b l e . Summarizing r e s e a r c h on the o c c u r r e n c e of OAEs i n humans r e p o r t e d i n the l i t e r a t u r e t o d a t e , McFadden (1982) found t h a t , whereas about s i x s u b j e c t s had tones t h a t c o r r e s p o n d e d t o d e t e c t a b l e OAEs (Kemp, 1981; W i l s o n & S u t t o n , 1981; Zurek, 1981), about s i x t y s u b j e c t s w i t h OAEs d i d not e x p e r i e n c e t i n n i t u s . In a d d i t i o n t h e r e have been r e p o r t s of numerous s u b j e c t s who have m u l t i p l e unheard OAEs accompanied i n some by a d d i t i o n a l heard OAEs. A l t h o u g h W i l s o n (1980) found a l i m i t e d c o r r e s p o n d e n c e between f r e q u e n c i e s of OAEs and peaks or t r o u g h s i n audiograms, the q u e s t i o n of whether t h e r e i s an a s s o c i a t i o n remains e q u i v o c a l . On the o t h e r hand, r e s e a r c h e r s have found a c l e a r e r a s s o c i a t i o n between f r e q u e n c i e s a t which h e a r i n g l o s s had o c c u r r e d and the f r e q u e n c i e s of OAEs ( G l a n v i l l e , C o l e s , & S u l l i v a n , 1971; H u i z i n g & Spoor, 1973). The q u e s t i o n of whether v a r i o u s q u a l i t i e s of OAEs and t i n n i t u s c o r r e s p o n d or not adds c o m p l e x i t y t o the i s s u e . That t h e r e i s a r e l a t i o n s h i p between OAEs and t i n n i t u s i n a t l e a s t c e r t a i n c a s e s i s suggested by the r e s u l t s of a m a n i p u l a t i o n i n which a i r p r e s s u r e i n the o u t e r - e a r 12 c a n a l was changed t o produce an upward s h i f t i n the fr e q u e n c y of the OAE. In some s u b j e c t s , the t i n n i t u s p i t c h was c o r r e s p o n d i n g l y e l e v a t e d (McFadden, 1982). W h i l e i t seemed t h a t the OAE had o f f e r e d g r e a t promise as a n a t u r a l l y o c c u r r i n g , o b j e c t i v e l y measurable, and t o some e x t e n t m a n i p u l a b l e , analogue t o t i n n i t u s , r e s e a r c h has t h u s f a r not been a b l e t o produce r e l i a b l e and p r e d i c t a b l e r e s u l t s d e s c r i b i n g the r e l a t i o n s h i p between OAEs and t i n n i t u s . Nor have the c o n d i t i o n s been d e s c r i b e d under which OAEs a r e e x p e r i e n c e d as t i n n i t u s and when they a r e n o t . C h a r a c t e r i s t i c s of t i n n i t e u r s . The phenomenology of t i n n i t u s i s not w e l l u n d e r s t o o d d e s p i t e the l a r g e volume of d a t a on t i n n i t u s c a s e s t h a t a c c u m u l a t e s i n many o t o l a r y n g o l o g i c a l c l i n i c s . One approach t o s y s t e m a t i c i n v e s t i g a t i o n would be t o a n a l y z e these d a t a i n o r d e r t o d i s c e r n whether t h e r e were a s p e c t s of the d i s o r d e r which tended t o c o - o c c u r . H a l l a m , Rachman, & H i n c h c l i f f e (1984) endeavoured t o s y s t e m a t i z e c h a r a c t e r i s t i c s of t i n n i t e u r s w i t h o u t i n t r o d u c i n g p r e c o n c e p t i o n s about e t i o l o g i e s , syndromes, or t r e a t m e n t response. They r e p o r t e d the r e s u l t s o b t a i n e d from a c l u s t e r a n a l y s i s u s i n g Ward's h i e r a r c h i c a l method ( E v e r i t t , 1974) on measures of 74 v a r i a b l e s s u p p l i e d on s e l f - r e p o r t q u e s t i o n n a i r e s . These were completed by 160 s u b j e c t s w i t h t i n n i t u s who had a t t e n d e d an o t o l a r y n g o l o g y c l i n i c f o r a v a r i e t y of e a r - r e l a t e d problems. The purpose of c l u s t e r a n a l y s i s i s t o 13 d e t e r m i n e p r o f i l e s of s c o r e s on t h e v a r i a b l e s c o n s i d e r e d which a r e t y p i c a l of c l u s t e r s of s u b j e c t s . T h e i r approach t o u s i n g the p r o f u s i o n of d a t a t h a t many o t o l a r y n g o l o g y c l i n i c s c o l l e c t i s p i o n e e r i n g and h e u r i s t i c a l l y f r u i t f u l . The c l u s t e r a n a l y s e s y i e l d e d 5 groups of t i n n i t u s s u f f e r e r s i n t h i s c a s e . One group was almost e x c l u s i v e l y male ( 8 7 % ) , and tended t o have r i g h t - s i d e d t i n n i t u s which was c o n t i n u o u s f o r j u s t over h a l f the group-members. D i z z i n e s s tended t o c o - o c c u r w i t h the t i n n i t u s sound and i n 75% of c a s e s d e a f n e s s was the main c o m p l a i n t . The second g r o u p i n g had the h i g h e s t p r o p o r t i o n of c ases c i t i n g n o i s e as a cause of the t i n n i t u s , and s t a t i n g t h a t n o i s e made the t i n n i t u s worse. In a d d i t i o n a h i g h p r o p o r t i o n had n o i s y j o b s and had f i r e d guns and 46% were i n v o l v e d i n m e d i c o - l e g a l c l a i m s . Without e x c e p t i o n , the s u b j e c t s i n t h i s c l u s t e r were males, and had d i z z i n e s s , b a l a n c e problems and nausea w i t h t h e l o w e s t f r e q u e n c y . I t had t h e h i g h e s t p r o p o r t i o n (90%) r e p o r t i n g d e a f n e s s as the main c o m p l a i n t and the h i g h e s t p r o p o r t i o n of those who had a n o t c h a t 4 kHz on t h e i r audiograms were members of t h i s group. Very few i n s t a n c e s of m i l d h e a r i n g l o s s were found h e r e , more se v e r e d e f i c i t s b e i n g more common. A d d i t i o n a l support f o r an e n v i r o n m e n t a l cause of the symptoms was t h a t o n l y 6% of r e l a t i v e s were deaf (compared w i t h 41% i n the p s y c h o g e n i c group d e s c r i b e d b e l o w ) . The t h i r d c l u s t e r i n g r e p o r t e d d i z z i n e s s as a symptom i n 100% of c a s e s and d i s p l a y e d h i g h r a t e s of b a l a n c e problems and 14 t r a v e l s i c k n e s s . There was a tendency f o r the t i n n i t u s t o have been l o n g s t a n d i n g (42% had had i t f o r 10 y e a r s or more). I n t e r e s t i n g l y , t h e r e were no c a s e s r e p o r t e d of t i n n i t u s o c c u r r i n g s o l e l y i n the l e f t e a r . No s u b j e c t d e s c r i b e d the sound as a buzz, nor found t h a t n o i s e made i t worse. H a l f of group members (more than any o t h e r group) had had a l l e r g i c r e a c t i o n s t o drugs or f o o d . Even though about a q u a r t e r of the group found t h a t the n o i s e s were g e t t i n g worse, i t had the low e s t o c c u r r e n c e of t i n n i t u s r e p o r t e d as the main c o m p l a i n t . Another c l u s t e r i n g of v a r i a b l e s i n t o what was d e s c r i b e d as a " p s y c h o g e n i c " group, c o n s i s t e d almost e n t i r e l y of females and had the h i g h e s t p r o p o r t i o n of u s e r s of p s y c h o - a c t i v e m e d i c a t i o n . There was a h i g h f r e q u e n c y too of somatic c o m p l a i n t s , m i g r a i n e s , headaches, b l u r r i n g of v i s i o n , p a l p i t a t i o n , and weight g a i n . V e s t i b u l a r problems o c c u r r e d w i t h the h i g h e s t p r e v a l e n c e . H a l f of the group members had p a i n or headache as an a d d i t i o n a l main c o m p l a i n t . Whereas no s u b j e c t s i n t h i s group d e s c r i b e d the t i n n i t u s sound as h i g h f r e q u e n c y t o n e , t h i s group had the h i g h e s t p r o p o r t i o n of members c h o o s i n g the d e s c r i p t o r "buzz". There was a c l e a r tendency f o r the onset of t i n n i t u s t o be r e c e n t (1 t o 2 y e a r s ) r a t h e r than l o n g - s t a n d i n g (10 or more y e a r s ) , and sudden r a t h e r t h a t g r a d u a l . The t i n n i t u s o c c u r r e d i n t e r m i t t e n t l y (92%) r a t h e r than b e i n g p r e s e n t c o n t i n u o u s l y . Every s i n g l e group member r e p o r t e d h a v i n g d i f f i c u l t y w i t h b a l a n c e and indeed one t h i r d had f a l l e n t o the ground w i t h o u t w a r n i n g . The a u t h o r s r a i s e d the p o s s i b i l i t y t h a t these c a s e s might be s i m i l a r i n some r e s p e c t s t o c h r o n i c p a i n s u f f e r e r s . 1 5 A f i n a l c l u s t e r i n g was r a t h e r l e s s d i s c r i m i n a b l e d e s c r i p t i v e l y than the o t h e r s . Perhaps most noteworthy was the tendency f o r t h e i r h e a r i n g l o s s t o be m i l d ( 71% under 20 dB) r a t h e r than s e v e r e ( o n l y 8% over 40 dB), a t r e n d not d i s p l a y e d by any o t h e r group. Whereas n e i t h e r age nor annoyance l e v e l of the t i n n i t u s d i s c r i m i n a t e d w e l l among the groups, l a t e r a l i t y of the t i n n i t u s , gender, and the l e n g t h of time s i n c e onset were i m p o r t a n t d i s c r i m i n a t o r s . H a l l a m , Rachman, & H i n c h c l i f f e (1984) found t h a t t h e r e were s i g n i f i c a n t d i f f e r e n c e s on o t h e r v a r i a b l e s t o o . S u b j e c t s w i t h t i n n i t u s as the t a r g e t c o m p l a i n t , compared t o t i n n i t e u r s w i t h o t h e r t a r g e t c o m p l a i n t s r e p o r t e d t h a t the p e r s i s t e n c e of the t i n n i t u s was the main reason f o r i t s o b j e c t i o n a b l e n a t u r e ; were more aware of the n o i s e s ; were more a f f e c t e d i n t h e i r w o r k i n g l i v e s by the t i n n i t u s ; were more l i k e l y t o have c o n s u l t e d a d o c t o r about i t ; tended t o have taken more p s y c h o t r o p i c m e d i c a t i o n ; had more t r o u b l e f a l l i n g a s l e e p ; and were more d e p r e s s e d . The a u t h o r s suggested t h a t one way of i n v e s t i g a t i n g the a s s o c i a t i o n between l o u d n e s s of t i n n i t u s and d i s t r e s s l e v e l s would be f o r t i n n i t e u r s who had f l u c t u a t i o n s i n the loudne s s t o r e c o r d r e p e a t e d r a t i n g s of t h i s , as w e l l as of d i s t r e s s l e v e l s . W i t h one e x c e p t i o n (the s i n g l e - c a s e study of M a l a t e s t a , S u t k e r , & Adams, 1980), n a t u r a l i s t i c m o n i t o r i n g has not been r e p o r t e d i n the l i t e r a t u r e t o d a t e . I t might a l s o be n e c e s s a r y t o do r e p e a t e d l o u d n e s s - m a t c h i n g e s t i m a t e s spaced over h o u r s , days and 16 weeks i n o r d e r t o e l u c i d a t e the phenomenology of t i n n i t u s . B. D e f i n i t i o n a l I s s u e s The f o l l o w i n g d e f i n i t i o n of t i n n i t u s was used i n t h i s p r o j e c t : t i n n i t u s i s the p e r c e p t i o n of i n t e r n a l sound l o c a l i z e d i n the head i n the absence of e x t e r n a l a c o u s t i c s t i m u l i . T h i s sound must be c o n s c i o u s l y e x p e r i e n c e d and not v o l u n t a r i l y p r o d u c i b l e . I t may or may not be accompanied by o t o a c o u s t i c e m i s s i o n s . T r a d i t i o n a l l y the d i s t i n c t i o n between o b j e c t i v e and s u b j e c t i v e t i n n i t u s has been based on whether the examining p r o f e s s i o n a l c o u l d or c o u l d not o b j e c t i v e l y d e t e c t a head-sound e i t h e r w i t h or w i t h o u t a s t e t h o s c o p e . As McFadden (1982) no t e d , t h i s dichotomy has been named v a r i o u s l y : v i b r a t o r y / n o n v i b r a t o r y ( F o w l e r , 1939,1941), o b j e c t i v e / s u b j e c t i v e , e x t r i n s i c / i n t r i n s i c ( A t k i n s o n , 1947), p s e u d o / t r u e (Jones & Knudsen, 1928). However, t h i s d i v i s i o n does not f u l l y c o v e r the phenomenology of head sounds. That the d e f i n i t i o n of t i n n i t u s demands "a c o n s c i o u s e x p e r i e n c e of a sound t h a t o r i g i n a t e s i n the head" i s emphasized by McFadden (1982, p.19). As d e s c r i b e d above, w i t h s o p h i s t i c a t e d d e t e c t i o n equipment now a v a i l a b l e , o t o a c o u s t i c e m i s s i o n s p r e v i o u s l y unknown ar e now d i s c e r n i b l e . Thus the s e n s i t i v i t y of i n s t r u m e n t a t i o n has become an i m p o r t a n t f a c t o r i n n o m enclature, b l u r r i n g the dichotomy between o b j e c t i v e and s u b j e c t i v e t i n n i t u s . McFadden (1982) a l s o l i s t e d o t h e r u n c o n t r o l l e d v a r i a b l e s which might a f f e c t d i a g n o s t i c d e c i s i o n - m a k i n g : "the i n t e n s i t y of the sound source [ i n the t i n n i t e u r ' s e a r ] , the amount of a t t e n u a t i o n from source 1 7 t o r e c e i v e r , the examiner's own h e a r i n g l e v e l i n the f r e q u e n c y r e g i o n of the s o u r c e , and the ambient n o i s e l e v e l i n t h a t f r e q u e n c y r e g i o n " ( p . 1 8 ) . C l e a r l y e x c l u d e d from our d e f i n i t i o n of t i n n i t u s , a r e such sounds as n e c k - c l i c k s and sounds heard when the jaws are m a n i p u l a t e d , s i n c e t h e s e can be v o l u n t a r i l y produced. McFadden (1982) r e v i e w e d the f o u r l o g i c a l p o s s i b i l i t i e s g e n e r a t e d by the presence or absence of o b j e c t i v e c o n c o m i t a n t s t o head-sounds and the p r e s e n c e or absence of the c o n s c i o u s p e r c e p t i o n of t h e s e sounds by the person p r o d u c i n g them. These are r e p r e s e n t e d d i a g r a m m a t i c a l l y i n F i g u r e 1. The d e f i n i t i o n of t i n n i t u s above c o v e r s o n l y c e l l 1, o b j e c t i v e t i n n i t u s (OAE d e t e c t e d and e x p e r i e n c e d ) , and c e l l 3, s u b j e c t i v e t i n n i t u s (no OAE d e t e c t e d but head sound e x p e r i e n c e d ) . The "unheard OAE" of c e l l 2 f a l l s o u t s i d e the scope of the d e f i n i t i o n of t i n n i t u s as t h e r e i s no p e r c e p t i o n of the OAE by i t s owner and our d e f i n i t i o n of t i n n i t u s r e q u i r e s t h i s p e r c e p t i o n t o be p r e s e n t . C. Measurement of T i n n i t u s The measurement of t i n n i t u s can be b r o a d l y d i v i d e d f o r c l i n i c a l r e s e a r c h purposes i n t o two a s p e c t s : the p h y s i c a l a t t r i b u t e s of the t i n n i t u s sound e.g. sound q u a l i t y , p i t c h , magnitude; and those d i r e c t e d towards i t s p s y c h o l o g i c a l c o n c o m i t a n t s e.g. d i s t r e s s l e v e l , i n t e r f e r e n c e w i t h d a i l y f u n c t i o n i n g , and e f f e c t on a f f e c t . S p e c t r a l l o c a t i o n p r o c e d u r e s attempt t o determine by 18 F i g u r e 1 C o m b i n a t i o n s of the p r e s e n c e / p e r c e p t i o n i n t e r a c t i o n f o r head sounds. Head-sound p e r c e i v e d by i t s producer Yes No 1 . 2. Pres e n c e of o b j e c t i v e l y d e t e c t e d Yes Heard OAE ( o b j e c t i v e t i n n i t u s ) Unheard OAE head-souund 3. 4. No S u b j e c t i v e t i n n i t u s No head-sound p e r c e i v e d or d e t e c t e d Note OAE o t o a c o u s t i c e m i s s i o n . 19 o b j e c t i v e p r o c e d u r e s what the p i t c h of the t i n n i t u s i s (McFadden, 1982). There a r e two methods of a c c o m p l i s h i n g t h i s . In p i t c h - m a t c h i n g the s u b j e c t i n d i c a t e s when a match has been a c h i e v e d between the p i t c h of the t i n n i t u s and a sound which i s v a r i e d by the examiner i n response t o v e r b a l feedback from the s u b j e c t . The sound i s u s u a l l y p r e s e n t e d t o the c o n t r a l a t e r a l ear ( f o r u n i l a t e r a l t i n n i t e u r s ) a f t e r i t has been equated f o r lou d n e s s w i t h the t i n n i t u s sound. A l t h o u g h p i t c h - m a t c h i n g might appear t o be the most d i r e c t way of d e t e r m i n i n g the p i t c h of a t i n n i t u s sound, i n p r a c t i c e i t p r e s e n t s problems. Octave e r r o r s can occur i n which the matched sound i s judged t o match the t i n n i t u s i n p i t c h but i s i n f a c t t w i c e or h a l f the f r e q u e n c y of the sound b e i n g matched (Vernon, 1977). The examiner s h o u l d be v i g i l a n t f o r t h e s e . The matching t a s k has proven t o be d i f f i c u l t f o r many n o v i c e and e x p e r i e n c e d t e s t e e s a l i k e (McFadden, 1982). H a z e l l (1981a) r e p o r t e d s i m i l a r d i f f i c u l t i e s , and f r e q u e n t l y t i n n i t e u r s a r e unable t o f i n d a match. As an a l t e r n a t i v e t o p i t c h - m a t c h i n g , a masking proc e d u r e has been used i n which a narrow-band sound i s p r e s e n t e d t o the ear w i t h the t i n n i t u s and i t s i n t e n s i t y i n c r e a s e d u n t i l the s u b j e c t r e p o r t s t h a t masking has been a c h i e v e d . T h i s i s r e p e a t e d i n s u c c e s s i v e s t e p s w i t h i n c r e a s i n g or d e c r e a s i n g f r e q u e n c y of the p r e s e n t e d t o n e . The t i n n i t u s p i t c h i s taken to be the one r e q u i r i n g the l e a s t i n t e n s i t y t o mask the t i n n i t u s . Voroba (1979a) r e p o r t e d t h a t when a s c e n d i n g or d e s c e n d i n g p i t c h was used, the t e s t - r e t e s t r e l i a b i l i t y f o r p i t c h - m a t c h i n g 20 p r o c e d u r e s was q u i t e low w i t h d i f f e r e n c e s r a n g i n g from 4 kHz t o 9kHz between p a i r s of t r i a l s . However, when the method of a d j u s t m e n t s , i n which the t e s t e e c o n t r o l s the t e s t tone f r e q u e n c y , was used, the v a r i a b i l i t y d e c r e a s e d . Masking p r o c e d u r e s have a l s o been used t o e s t i m a t e the magnitude of t i n n i t u s . The assumption was t h a t the g r e a t e r the magnitude r e q u i r e d of the p r e s e n t e d sound t o mask t h e t i n n i t u s , the g r e a t e r the magnitude of the t i n n i t u s . As McFadden (1982) has p o i n t e d o u t , t h e r e i s not a c l e a r r e l a t i o n s h i p between the two i n t e n s i t i e s . The r e l a t i v e w i d t h s of the n o i s e band and of the t i n n i t u s sound would a f f e c t masking i n t e n s i t y . Some t i n n i t e u r s have found masking t o be e q u a l l y e f f e c t i v e a t almost any fre q u e n c y whereas o t h e r s have t i n n i t u s sounds which cannot be masked r e g a r d l e s s of masking tone f r e q u e n c y . Feldmann (1971) termed t h i s group as h a v i n g " r e s i s t a n c e - t y p e t i n n i t u s . " The " s u b j e c t i v e " methods of r e p o r t i n g t i n n i t u s p i t c h have shown poor c o r r e l a t i o n s w i t h the p i t c h d e t e r m i n e d o b j e c t i v e l y ( H a z e l l , 1981a). A h i g h e r c o r r e l a t i o n has been r e p o r t e d between s e l f - r a t i n g s of the s u b j e c t i v e l o u d n e s s of t i n n i t u s and a f r e e f i e l d s y n t h e s i s matching p r o c e d u r e , than w i t h masking i n t e n s i t y l e v e l ( H a z e l l , 1981a). Free f i e l d s y n t h e s i s i n v o l v e s e x p o s i n g the s u b j e c t t o a sound as c l o s e as p o s s i b l e i n p i t c h t o the t i n n i t u s sound, and then a d j u s t i n g the i n t e n s i t y of t h i s s y n t h e t i c sound u n t i l i t i s i m p o s s i b l e f o r the t i n n i t e u r t o dete r m i n e whether the sound o r i g i n a t e d i n t e r n a l l y or from the s y n t h e s i s e r . 21 -Another t e c h n i q u e i n magnitude e s t i m a t i o n i s lo u d n e s s matching. A sound which i s matched as c l o s e l y as p o s s i b l e i n p i t c h and q u a l i t y t o the t i n n i t u s i s p r e s e n t e d t o the c o n t r a l a t e r a l e a r . The s u b j e c t e i t h e r a d j u s t s the i n t e n s i t y of the s y n t h e s i z e d sound or i n s t r u c t s the examiner t o do so, u n t i l t he i n t e n s i t i e s of the two sounds a r e judged t o be e q u a l . A l t h o u g h Vernon, Johnson, S c h l e u n i n g , and M i t c h e l l (1980) r e p o r t e d h i g h t e s t - r e t e s t r e l i a b i l i t y ( w i t h i n 1dB i n most c a s e s ) i n l o u d n e s s matching, McFadden (1982) r e p o r t e d c o n s i d e r a b l y lower r e l i a b i l i t y w i t h even n o r m a l - h e a r i n g s u b j e c t s . T h i s method has i t s own problems (McFadden, 1982): 1. There i s an i n t e r d e p e n d e n c y between q u a l i t y , p i t c h , and loudness judgement. Thus the c h o i c e of a matching loudn e s s might be re n d e r e d l e s s a c c u r a t e because the p i t c h had not been a c c u r a t e l y matched. 2. When the t i n n i t u s i s b i n a u r a l , the ear t o which the matching sound i s p r e s e n t e d might be an i m p e r f e c t i n s t r u m e n t f o r j u d g i n g l o u d n e s s . 3. When a s u b j e c t has t i n n i t u s b i n a u r a l l y , the problem a r i s e s as how t o combine the measurements of both e a r s so as best t o r e p r e s e n t the o v e r a l l e x p e r i e n c e of the t i n n i t e u r . 4. Feldmann (1971) has found t h a t c o n t r a l a t e r a l masking i s p o s s i b l e . In loudnes s m a t c h i n g , t h e r e f o r e , i t i s p o s s i b l e t h a t some masking of the t i n n i t u s can o c c u r . Thus the v e r y t a r g e t of measurement c o u l d be a f f e c t e d by the t e c h n i q u e used. 5. I f t h e r e was r e c r u i t m e n t or h e a r i n g impairment i n the ear t o which the e x t e r n a l tone was p r e s e n t e d , an i n c o r r e c t 22 e s t i m a t e of the t i n n i t u s magnitude c o u l d r e s u l t : Goodwin and Johnson (1980) t e s t e d the Vernon r e c r u i t m e n t h y p o t h e s i s and found support f o r i t . They compared l o u d n e s s matching when performed by the t r a d i t i o n a l method of p r e s e n t i n g comparison tones t o the ear c o n t r a l a t e r a l t o t h e t i n n i t u s , w i t h an i p s i l a t e r a l method i n which l o u d n e s s matching judgements were made f o r tones p r e s e n t e d t o the ear w i t h t i n n i t u s . Without e x c e p t i o n e v e r y comparison of the two methods found h i g h e r e s t i m a t e s from the i p s i l a t e r a l method. T h i s c o u l d w e l l be because t i n n i t u s magnitude tended t o be u n d e r e s t i m a t e d by the t r a d i t i o n a l b i n a u r a l method due t o r e c r u i t m e n t e f f e c t s . 6. P r o c e d u r a l d i f f e r e n c e s c o u l d l e a d t o d i f f e r e n t magnitude e s t i m a t e s . A s e r i e s of tones w i t h d e s c e n d i n g i n t e n s i t i e s might w e l l cause some r e s i d u a l i n h i b i t i o n . The i n i t i a l h i g h i n t e n s i t y tones c o u l d t h e r e f o r e r e s u l t i n an u n d e r e s t i m a t e of the t i n n i t u s magnitude. For t h i s r e a s o n , an a s c e n d i n g s e r i e s p r o t o c o l might be p r e f e r a b l e (Vernon et a l . , 1980). H a l l a m , J a k e s , Chambers, & H i n c h c l i f f e (1985) i n v e s t i g a t e d the r e l a t i o n s h i p between d i f f e r e n t ways of measuring t i n n i t u s i n t e n s i t y ( i n c l u d i n g s u b j e c t i v e r a t i n g s and a u d i o l o g i c a l measurement) and p s y c h o l o g i c a l a s p e c t s of t i n n i t u s c o m p l a i n t ( i n c l u d i n g d i s t r e s s and i n t r u s i v e n e s s ) . A u d i o l o g i c a l measurement based on t h r e s h o l d e s t i m a t i o n , l o u d n e s s m atching, or masking l e v e l s were found not t o be s i g n i f i c a n t l y c o r r e l a t e d w i t h p s y c h o l o g i c a l s c a l e s . Measurements based on p e r s o n a l l o u d n e s s u n i t s (PLUs) were s i g n i f i c a n t l y c o r r e l a t e d w i t h t h e s e 23 s c a l e s . PLUs were d e r i v e d by t r a n s f o r m i n g sound l e v e l s which c o r r e s p o n d e d t o v a r i o u s m u l t i p l e s of the "most c o m f o r t a b l e l o u d n e s s l e v e l " by a f u n c t i o n d e s c r i b i n g growth of l o u d n e s s f o r an i n d i v i d u a l . PLUs were a l l s i g n i f i c a n t l y c o r r e l a t e d w i t h s u b j e c t i v e r a t i n g s of t i n n i t u s l o u d n e s s whereas a u d i o l o g i c a l e s t i m a t e s of t i n n i t u s l o u d n e s s were n o t . R e c e n t l y , J a k e s , H a l l a m , Chambers, and H i n c h l i f f e (1986) i n v e s t i g a t e d the reasons f o r the g e n e r a l l y low c o r r e l a t i o n s found between s e l f - r e p o r t e d and matched l o u d n e s s . They a t t r i b u t e d t h i s t o measurement problems of two t y p e s : s u b j e c t s who d i d not u n d e r s t a n d the s e l f -r e p o r t s c a l e s and poor c h o i c e of s e l f - r e p o r t s c a l e t y p e . Guttman and a d j e c t i v a l s c a l e s y i e l d e d h i g h e s t c o r r e l a t i o n s w i t h l o u d n e s s match v a l u e s . R a t h e r than a t t e m p t i n g t o measure the p i t c h o b j e c t i v e l y , t i n n i t e u r s might be asked t o d e s c r i b e v e r b a l l y the c h a r a c t e r i s t i c s of the sound they heard. In a v a r i a t i o n of t h i s a pproach, the examiner p r e s e n t s a l i s t of d e s c r i p t o r s and asks f o r the word which most c l o s e l y r e p r e s e n t s the t i n n i t u s sound heard. D e s c r i p t o r s p r o v i d e d by t i n n i t e u r s have not proved u s e f u l i n p r o v i d i n g c l u e s as t o the e t i o l o g y of the t i n n i t u s p r e s e n t . T h i s might be because t h e r e i s no r e l i a b l e c o r r e s p o n d e n c e between the r e p o r t e d c h a r a c t e r i s t i c s of t i n n i t u s and i t s p a t h o l o g y ; or because the v e r b a l s k i l l s of the t i n n i t e u r might p r e c l u d e an a c c u r a t e d e s c r i p t i o n (McFadden and Wightman, 1983). C r o s s - m o d a l i t y m a t c h i n g , as a method of measuring the 24 l o u d n e s s of t i n n i t u s , has not been r e p o r t e d i n the t i n n i t u s l i t e r a t u r e . In t h i s method the s u b j e c t e x p r e s s e s the i n t e n s i t y of a t a r g e t s e n s a t i o n by a d j u s t i n g the i n t e n s i t y of a measurable a s p e c t i n a d i f f e r e n t s ensory m o d a l i t y . Thus i n p a i n r e s e a r c h , the i n t e n s i t y of p a i n has been measured by the s t r e n g t h of g r i p e x e r t e d on a dynamometer ( G r a c e l y , 1979). I t has been w e l l documented t h a t t i n n i t u s f l u c t u a t e s over time both i n p i t c h and i n t e n s i t y . H a z e l l ( 1 9 8 1 c ) , f o r example, found t h a t 8% of h i s sample of t i n n i t e u r s r e p o r t e d t h a t i t s presence/absence f l u c t u a t e d a t about h o u r l y i n t e r v a l s and a s i m i l a r p r o p o r t i o n e x p e r i e n c e d c y c l e s w i t h a p e r i o d of one day. About 8% had a c o n t i n u o u s l y c h a n g i n g p i t c h w i t h about the same per c e n t a g e r e p o r t i n g more i n t e r m i t t e n t p i t c h v a r i a b i l i t y . T h i s v a r i a b i l i t y i n the t e m p o r a l a s p e c t s of t i n n i t u s has i m p o r t a n t i m p l i c a t i o n s f o r i t s measurement. N e v e r t h e l e s s , a survey of the l i t e r a t u r e y i e l d e d o n l y one r e p o r t , the s i n g l e - c a s e study of M a l a t e s t a , e t a l . , (1980), t h a t c o m p r e h e n s i v e l y documented i n t r a s u b j e c t v a r i a b i l i t y of t i n n i t u s i n t e n s i t y . In t h i s case the i n t e n s i t y was h i g h e s t l a t e a t n i g h t , l o w e s t e a r l y i n the morning, w i t h a f t e r n o o n at an i n t e r m e d i a t e l e v e l . T h i s p a t t e r n i s p r o b a b l y i d i o s y n c r a t i c s i n c e , i n a study c i t e d e a r l i e r ( T y l e r and Baker, u n d a t e d ) , 16.6% of members of a s e l f - h e l p group r e p o r t e d t h a t the t i n n i t u s was most troublesome i n the morning. F o r t y - o n e p e r c e n t of H a z e l l ' s s u b j e c t s found t h a t t i n n i t u s i n t e n s i t y was not a s s o c i a t e d w i t h time of day. The i s s u e of p e r i o d i c f l u c t u a t i o n i n t i n n i t u s i n t e n s i t y has not been e x p e r i m e n t a l l y i n v e s t i g a t e d . Hallam et a l . (1985) r e p o r t e d 25 t e s t - r e t e s t c o r r e l a t i o n s of between .57 and .75 over 1-6 months f o r a u d i o l o g i c a l l o u d n e s s matching and t i n n i t u s f r e q u e n c y . R e s e a r c h r e p o r t e d t o date has not i s o l a t e d the e f f e c t of time of day from o t h e r p o t e n t i a l l y s i g n i f i c a n t f a c t o r s such as a r o u s a l l e v e l , l e v e l of f a t i g u e , and presence of d i s t r a c t i n g a c t i v i t i e s . These might c o v a r y w i t h each o t h e r and w i t h time of day. F l u c t u a t i o n s i n the a t t r i b u t e s and e f f e c t s of t i n n i t u s s h o u l d be taken i n t o account as d e s i g n f a c t o r s i n t i n n i t u s r e s e a r c h . D. E p i d e m i o l o g y The e p i d e m i o l o g y of t i n n i t u s has been r e s e a r c h e d u s i n g f o u r d i f f e r e n t samples: demographic s u r v e y s , o t o l a r y n g o l o g y c l i n i c p a t i e n t s , n o r m a l l y - h e a r i n g n o n - c l i n i c a d u l t s , and h e a r i n g -i m p a i r e d c h i l d r e n . In a w e l l - d e s i g n e d demographic s t u d y , a survey of a random sample of v o t e r s i n f o u r B r i t i s h c i t i e s was undertaken ( M e d i c a l Research C o u n c i l ' s I n s t i t u t e of H e a r i n g R e s e a r c h , 1981). T i n n i t u s was o p e r a t i o n a l l y d e f i n e d f o r p a r t i c i p a n t s f o r p a r t i c i p a n t s as " r i n g i n g or b u z z i n g n o i s e s i n your head or e a r s . The o c c a s i o n a l w h i s t l i n g or r i n g i n g i n the e a r s of l e s s than f i v e minutes d u r a t i o n s h o u l d not be co u n t e d . A l s o do not count those t i m e s when t h i s happens a f t e r v e r y l o u d sounds, e.g. d i s c o s , s h o o t i n g or n o i s e a t work." When t i n n i t u s was d e f i n e d i n t h i s way i t was found t h a t the mean p r e v a l e n c e of s e l f -r e p o r t e d t i n n i t u s a c r o s s the sample was 17.5% (range a c r o s s c i t i e s 15.5% t o 18.6%). About 9% (range 8.3% t o 9.6%) of resp o n d e n t s r e p o r t e d t i n n i t u s w i t h o u t accompanying h e a r i n g 26 impairment and 8.5% (range 7.2% t o 9.4%) had b o t h . The r e l a t i v e s t a b i l i t y a c r o s s c i t i e s of the s t a t i s t i c s o b t a i n e d was notew o r t h y . The study a l s o showed the e f f e c t t h a t v a r y i n g the o p e r a t i o n a l d e f i n i t i o n of t i n n i t u s had on p r e v a l e n c e e s t i m a t e s . In the p i l o t s u r v ey of t h i s s t u d y 39% of the sample r e p o r t e d the pre s e n c e of t i n n i t u s when spontaneous, s h o r t - d u r a t i o n ( l e s s than f i v e minutes) head or ear n o i s e s were not e x c l u d e d . The a u t h o r s a d v i s e t h i s e x c l u s i o n t o a r r i v e a t a c l i n i c a l l y r e l e v a n t d e f i n i t i o n which would not i n c l u d e "normal" t i n n i t u s and temporary t i n n i t u s f o l l o w i n g n o i s e exposure. H i n c h c l i f f e (1961) d i d not s p e c i f y how t i n n i t u s was d e f i n e d i n h i s random s a m p l i n g of r u r a l p o p u l a t i o u s i n Great B r i t a i n and o b t a i n e d an o v e r a l l p r e v a l e n c e a c r o s s a l l ages of 29%, p r o b a b l y because of a l o o s e r d e f i n i t i o n . H e a r i n g impairment i n the MRC study was o p e r a t i o n a l l y d e f i n e d as a n e g a t i v e response t o the q u e s t i o n : "Can you u s u a l l y hear and u n d e r s t a n d what a pers o n says t o you i n a q u i e t room, i f he w h i s p e r s t o you?" T h i s sample y i e l d e d a mean r a t e of h e a r i n g impairment w i t h no t i n n i t u s p r e s e n t of 17.6% (range 15.2% t o 18.9%). About t w o - t h i r d s of the t o t a l sample were n e i t h e r h e a r i n g i m p a i r e d nor had t i n n i t u s . Rates f o r the a s p e c t s of h e a r i n g and t i n n i t u s measured were c o n s i s t e n t a c r o s s the f o u r c i t i e s s u r v e y e d . A s u r v e y of U.S. a d u l t s found t h a t 32% r e p o r t e d h a v i n g had t i n n i t u s at l e a s t once d u r i n g t h e i r l i v e s ( V i t a l and H e a l t h S t a t i s t i c s , 1968). No demographic survey of t i n n i t u s p r e v a l e n c e has been c a r r i e d out i n Canada 27 ( S t a t i s t i c s Canada, p e r s o n a l communication, August, 1983). I t i s c l e a r t h a t the p r e v a l e n c e of t i n n i t u s i s s u b s t a n t i a l and t h a t e s t i m a t e s of i t s o c c u r r e n c e a r e a f f e c t e d by the s t r i n g e n c y of c r i t e r i a i n d e f i n i n g i t . O t o l a r y n g o l o g y c l i n i c p a t i e n t s have been the s u b j e c t of a number of s t u d i e s : 85% of a sample of 2000 c o n s e c u t i v e p a t i e n t s w i t h v a r i o u s p r e s e n t i n g problems had t i n n i t u s ( F o w l e r , 1944); 73% of 100 c o n s e c u t i v e "hard of h e a r i n g p a t i e n t s " were t i n n i t e u r s ( H e l l e r & Bergman, 1953); 83% of 500 c o n s e c u t i v e p a t i e n t s w i t h a c o u s t i c neuromas c o m p l a i n e d of t i n n i t u s (House & Brackmann, 1981); and 79% of 190 p a t i e n t s w i t h o t o s c l e r o s i s had t i n n i t u s ( G l a s g o l d & Altmann, 1966). In one r e p o r t (Singerman, R i e d n e r , & F o l s t e i n , 1980) o t o l a r y n g o l o g y c l i n i c p a t i e n t s were grouped a c c o r d i n g t o h e a r i n g d e f i c i t l e v e l as d e t e r m i n e d by p u r e - t o n e a u d i o l o g i c a l t e s t i n g and a l s o by speech d i s c e r n a b i 1 i t y s c o r e s . Of the n o r m a l - h e a r i n g c l i n i c subgroup, 17% had t i n n i t u s a l o n e and 48% had t i n n i t u s w i t h accompanying v e s t i b u l a r problems (a t o t a l p r e v a l e n c e of t i n n i t u s of 6 5 % ) . An a n a l y s i s of the d a t a from t h i s study showed t h a t 24% of the t o t a l sample r e p o r t e d h a v i n g t i n n i t u s w i t h no v e s t i b u l a r problems ( a l t h o u g h no o p e r a t i o n a l d e f i n i t i o n f o r t i n n i t u s was p u b l i s h e d ) and 44% had t i n n i t u s w i t h v e s t i b u l a r problems. Thus 68% of the f u l l sample had t i n n i t u s as a symptom. These f i n d i n g s suggest t h a t f o r o t o l a r y n g o l o g y c l i n i c p o p u l a t i o n s , w h i l e t h e r e i s a h i g h p r e v a l e n c e of t i n n i t u s , i n c r e a s i n g l e v e l s of h e a r i n g impairment a r e not a s s o c i a t e d w i t h i n c r e a s i n g p r e v a l e n c e of t i n n i t u s . 28 O v e r a l l , between 68% and 85% of o t o l a r y n g o l o g y c l i n i c p a t i e n t s i n the s t u d i e s c i t e d had t i n n i t u s as the p r i m a r y symptom or s e c o n d a r i l y t o o t o l a r y n g o l o g i c a l problems. H e l l e r & Bergman (1953) found t h a t , of a sample of 80 normal h e a r i n g h e a l t h y a d u l t s , 94% r e p o r t e d d e t e c t i n g some t i n n i t u s - l i k e sound i n the e a r s w h i l e p l a c e d i n a sound-proof room f o r f i v e m i n u t e s . I t c o u l d w e l l be t h a t , a l t h o u g h t h e s e sounds a r e p r e s e n t c o n t i n u a l l y , they a r e masked by ambient n o i s e and are o n l y n o t i c e d i n an environment where the ambient n o i s e l e v e l i s reduced. The age-range of the sample was from 18 t o 60 y e a r s and the p o s s i b i l i t y t h a t the p r e v a l e n c e of ear-sounds heard was a g e - r e l a t e d was not d i s c u s s e d . In c o n t r a s t t o H e l l e r & Bergman's r e p o r t , Graham & Newby (1967) found t h a t o n l y 40% of t h e i r n o r m a l l y - h e a r i n g s u b j e c t s r e p o r t e d h e a r i n g t i n n i t u s sounds i n a s o u n d - a t t e n u a t e d room. Graham & Newby p o i n t e d out t h a t H e l l e r & Bergman d i d not t e s t t h e i r " n o r m a l l y - h e a r i n g " s u b j e c t s a u d i o m e t r i c a l l y but r a t h e r r e l i e d on s e l f - r e p o r t w i t h r e s p e c t t o h e a r i n g a b i l i t y . Graham & Newby suggested t h a t t h e i r e s t i m a t e was more a c c u r a t e because 44% of t h e i r s u b j e c t s who r e p o r t e d h a v i n g normal h e a r i n g , d i d not meet t h e i r c r i t e r i a f o r normal h e a r i n g when t e s t e d a u d i o m e t r i c a l l y . They found t h a t normal-h e a r i n g s u b j e c t s who c o u l d d e t e c t t i n n i t u s sounds o n l y i n a s o u n d - t r e a t e d room, s u b j e c t i v e l y r e p o r t e d s i g n i f i c a n t l y q u i e t e r t i n n i t u s than t i n n i t e u r s w i t h h e a r i n g - l o s s . McFadden (1982) p o i n t e d out t h a t i t was v e r y common f o r m i l d t i n n i t u s t o be e x p e r i e n c e d o c c a s i o n a l l y and t h a t t h i s was 29 not n e c e s s a r i l y a s s o c i a t e d w i t h a u d i t o r y p a t h o l o g y . I t was t h e r e f o r e i m p o r t a n t f o r r e s e a r c h e r s t o d e f i n e t i n n i t u s unambiguously so as t o i n c l u d e o n l y those c a s e s of c l i n i c a l s i g n i f i c a n c e . Graham (1981b) s u r v e y e d h e a r i n g - i m p a i r e d c h i l d r e n aged 12-18 y e a r s i n two l o c a t i o n s : p a r t i a l - h e a r i n g u n i t s (PHUs) and a t s c h o o l s f o r the deaf ( a t t e n d e d by c h i l d r e n who were more s e r i o u s l y h e a r i n g - i m p a i r e d ) . S i x t y - s i x p e r c e n t of c h i l d r e n s u r v e y e d a t PHUs r e p o r t e d h a v i n g had t i n n i t u s c o n f i r m i n g an e a r l i e r s tudy (Graham 1981a) and 29% of those a t the s c h o o l s . U n l i k e the MRC s u r v e y , however, Graham d i d not e x c l u d e f l e e t i n g , o c c a s i o n a l e p i s o d e s from h i s s t u d y t h u s l e a v i n g the u n c e r t a i n t y as t o whether th e s e h i g h p r e v a l e n c e s r e s u l t e d from the more encompassing d e f i n i t i o n of t i n n i t u s , or as a r e s u l t of the f a c t t h a t the sample c o n s i s t e d of h e a r i n g - i m p a i r e d c h i l d r e n , or f o r b o t h r e a s o n s . I f a group of n o r m a l - h e a r i n g c h i l d r e n had been i n c l u d e d , t h e r e would be l e s s u n c e r t a i n t y i n t h i s r e g a r d . However, Graham's r e p o r t was s u f f i c i e n t l y d e t a i l e d f o r some approximate a d j u s t m e n t s t o be made i n a r e a n a l y s i s of h i s d a t a , so t h a t h i s d e f i n i t i o n of t i n n i t u s might c o r r e s p o n d more c l o s e l y w i t h the MRC d e f i n i t i o n . C a l c u l a t i o n s were made t o e x c l u d e c h i l d r e n who r e p o r t e d t i n n i t u s o c c u r r i n g monthly or l e s s f r e q u e n t l y , or whose t i n n i t u s had a d u r a t i o n of l e s s than 5 minutes per e p i s o d e . E s t i m a t e d p r e v a l e n c e s of t i n n i t u s then dropped t o 10% of the c h i l d r e n i n the PHUs and 6% of those i n the s c h o o l s f o r deaf c h i l d r e n . These r a t e s of o c c u r r e n c e were more i n k e e p i n g w i t h the p o s t u l a t i o n t h a t p r e v a l e n c e of t i n n i t u s i s lower f o r younger age groups (whether or not one assumes t h a t 30 h e a r i n g - i m p a i r e d c h i l d r e n have a h i g h e r l i k e l i h o o d of h a v i n g t i n n i t u s ) . I t was noteworthy t h a t i n b o t h the r e p o r t e d and reworked p r e v a l e n c e s , t h e r e was a h i g h e r p r o b a b i l i t y f o r t i n n i t u s t o occur i n the PHUs than i n the s c h o o l s f o r the deaf; and a l s o f o r i t t o occur i n the b e t t e r - h e a r i n g e a r . No c l e a r e x p l a n a t i o n has been p o s s i b l e f o r t h e s e f i n d i n g s which run c o u n t e r t o t h e g e n e r a l l y - h e l d b e l i e f t h a t t i n n i t u s i s c l o s e l y a s s o c i a t e d w i t h ear p a t h o l o g i e s , and s u p p o r t the f i n d i n g s of Singerman, R i e d n e r , & F o s t e i n (1980) r e f e r r e d t o above. A l t h o u g h i t s u f f e r e d from a number of m e t h o d o l o g i c a l and r e p o r t i n g problems, the study by Nodar (1972) i s the s o l e example of a l o n g i t u d i n a l s tudy i n the t i n n i t u s l i t e r a t u r e . He f o l l o w e d over 2000 n o r m a l - h e a r i n g s c h o o l c h i l d r e n aged 10-18 y e a r s f o r t h r e e y e a r s and found the f o l l o w i n g : the p r e v a l e n c e of t i n n i t u s i s a p p r o x i m a t e l y n o r m a l l y d i s t r i b u t e d over the time p e r i o d of the study w i t h the p r e v a l e n c e a t 13-15 y e a r s (44%) almost d o u b l e t h a t a t ages 10-11 y e a r s (23%) and a t 17-18 y e a r s ( 1 4 % ) ; o v e r a l l p r e v a l e n c e was 15.2% over a l l ages and over the t h r e e y e a r s of c o n d u c t i n g the s t u d y ; f o u r t i m e s as many c h i l d r e n who were found t o have h e a r i n g problems (as i n d i c a t e d by a u d i o m e t r i c t e s t i n g i n the c o u r s e of the s u r v e y ) r e p o r t e d h a v i n g t i n n i t u s compared t o those w i t h b e t t e r h e a r i n g a b i l i t y . T h i s study used the broader d e f i n i t i o n of t i n n i t u s ( w i t h o u t e x c l u s i o n s of t e m p o r a r i n e s s of t i n n i t u s o c c u r r e n c e s ) , and the e s t i m a t e s of t i n n i t u s p r e v a l e n c e were t h e r e f o r e l i k e l y t o be o v e r s t a t e d t o i n c l u d e f l e e t i n g and o c c a s i o n a l n o i s e s commonly heard but not i n c l u d e d i n a more r i g o r o u s d e f i n i t i o n . 31 The MRC study of the g e n e r a l p o p u l a t i o n found more l e f t -s i d e d t i n n i t u s (4.6%) than r i g h t - s i d e d t i n n i t u s (3.4%) and 9.7% r e p o r t e d t i n n i t u s b i l a t e r a l l y or i n the head. H a z e l l (1981b) and Reed ( i 9 6 0 ) a l s o found a h i g h e r p r o p o r t i o n of l e f t - s i d e d t i n n i t u s . S t u d i e s where l a t e r a l i z a t i o n d a t a a r e p r e s e n t e d or where d a t a c o u l d be r e a n a l y z e d t o y i e l d i n f o r m a t i o n on l a t e r a l i z a t i o n , a r e p r e s e n t e d i n T a b l e 1. The c o n s i s t e n c y of the a p p r o x i m a t e l y 50% h i g h e r p r e v a l e n c e of l e f t - s i d e d compared t o r i g h t - s i d e d t i n n i t u s i n a d u l t s d e s p i t e the d i v e r s i t y of the samples used i s s t r i k i n g . The n o t a b l e e x c e p t i o n i n a d u l t d a t a i s the H a l l a m , Rachman, & H i n c h c l i f f e study where r i g h t - s i d e d exceeded l e f t - s i d e d t i n n i t u s by about 50%. No c o n f i d e n t e x p l a n a t i o n f o r t h i s c o u l d be o f f e r e d . In c o n t r a s t t o the a d u l t sample, i n c h i l d r e n t i n n i t u s seemed t o occur w i t h a p p r o x i m a t e l y e q u a l p r o b a b i l i t y i n l e f t and r i g h t e a r s . S e v e r a l e x p l a n a t i o n s have been o f f e r e d as t o why t i n n i t u s i n a d u l t s was found t o be more p r e v a l e n t i n the l e f t ear (Reed, 1960; Vernon, 1977; H a z e l l , 1979; MRC, 1981). D a v i s & W e i l e r (1978) found t h a t t h e r e i s s u p e r i o r a u d i t o r y a d a p t a t i o n t o pure tones i n the r i g h t ear compared t o the l e f t e a r . H a l l a m , Rachman, & H i n c h c l i f f e (1984) compared c h a r a c t e r i s t i c s of 160 l e f t - s i d e d , r i g h t - s i d e d , and b i l a t e r a l t i n n i t e u r s . Those s u f f e r e r s l a t e r a l i z e d t o the l e f t were l e s s l i k e l y t o have had a n o i s y j o b , t o have e x p e r i e n c e d g u n f i r e , or t o have had h e a r i n g l o s s as a main c o m p l a i n t , and they were more l i k e l y t o have had more y e a r s of e d u c a t i o n . Those l a t e r a l i z e d t o the r i g h t were l e s s l i k e l y t o have r e p o r t e d t h a t n o i s e made the t i n n i t u s worse 32 Ta b l e 1 Summary of Si d e d n e s s of T i n n i t u s from L i t e r a t u r e Sample Re f e r e n c e R a t i o s B H e a r i n g - i m p a i r e d c h i l d r e n H e a r i n g - i m p a i r e d c h i l d r e n O t o l a r y n g o l o g y c l i n i c ( G e n e r a l ) O t o l a r y n g o l o g y c l i n i c ( A d u l t - t i n n i t u s p r i m a r y symptom) Random survey ( G e n e r a l A d u l t P o p u l a t i o n ) O t o l a r y n g o l o g y c l i n i c ( G e n e r a l A d u l t P o p u l a t i o n ) T h i s study ( G e n e r a l A d u l t P o p u l a t i o n ) Graham, 1981a Graham, 1981b 74 78 Ha l l a m , Rachman, 160 & H i n c h c l i f f e , 1984 H a z e l l , 1981b M.R.C., 1981 Reed, 1960 131 60 60 1 .7 1 .6 2.3 0.9 1 .8 3.9 0.7 0.8 0.9 0.7 1 .6 1 .5 a. 5,000 2.9 1.4 1 200 2.1 1.4 1 1.8 1 1.1 1 Note. B b i l a t e r a l t i n n i t u s ( i n c l u d e s head as s i t e ) L l e f t - s i d e d t i n n i t u s R r i g h t - s i d e d t i n n i t u s a c a l c u l a t i o n from d a t a s u p p l i e d b c a l c u l a t i o n from bar c h a r t c b i l a t e r a l but m a i n l y o n e - s i d e d i n c l u d e d i n B d b i l a t e r a l but m a i n l y o n e - s i d e d i n c l u d e d i n L or R 33 and more l i k e l y t o have had an ear o p e r a t i o n . B i l a t e r a l i t y was a s s o c i a t e d w i t h n o i s e - e x p o s u r e a t work, onset of t i n n i t u s accompanied by h e a r i n g l o s s , n o i s e making t i n n i t u s worse, and n o i s e s u s p e c t e d as cause of the t i n n i t u s . The h y p o t h e s i s t h a t the n o i s e from l e f t - s i d e d r i f l e - f i r e c o n t r i b u t e d t o more l e f t -s i d e d t i n n i t u s was not s u p p o r t e d but t h e r e was support f o r an a s s o c i a t i o n between n o i s e exposure and b i l a t e r a l t i n n i t u s . The a u t h o r s propose t h a t , s i n c e l e f t - s i d e d t i n n i t e u r s tended t o form a n o r m a l l y - h e a r i n g , h i g h e r o c c u p a t i o n a l group w i t h l i t t l e e xposure t o j o b n o i s e , i t might be t h a t an a u d i t o r y d i a t h e s i s e x p l a n a t i o n was a p p r o p r i a t e . There has been no r e s e a r c h r e p o r t e d on whether t h e r e a r e r e l i a b l e s t r u c t u r a l d i f f e r e n c e s between the l e f t and r i g h t h e a r i n g a p p a r a t u s e s . However, a l t h o u g h e x t e r n a l l y the body i s g e n e r a l l y p e r c e i v e d t o be s y m m e t r i c a l , i t i s t r u e t h a t i n t e r n a l l y symmetry seems t o be more the e x c e p t i o n than the r u l e . W h i l e t h e r e have been no s y s t e m a t i c a t t e m p t s t o l i n k s omatic asymmetry w i t h the d i f f e r e n t i a l p r e v a l e n c e between l e f t and r i g h t s i d e d t i n n i t u s , t h i s i s an ar e a which might p r o f i t a b l y be e x p l o r e d . I t has a l s o been suggested t h a t , a t a h i g h e r c o r t i c a l l e v e l , the combined p e r c e p t i o n of b i l a t e r a l t i n n i t u s sounds might be a t t e n d e d t o on the l e f t . T h i s might be because the l e f t sound might be l o u d e r i n b i l a t e r a l t i n n i t u s ( H a l l a m , Rachman, & H i n c h c l i f f e , 1984). I t might be i m p o r t a n t t o note t h a t f o r c h i l d r e n , t i n n i t u s appeared w i t h a p p r o x i m a t e l y e q u a l p r e v a l e n c e on the l e f t and r i g h t s i d e s and t h a t the l e f t predominance was more p r e v a l e n t i n a d u l t s . T h i s would suggest 34 an e n v i r o n m e n t a l exposure f a c t o r of e i t h e r s i n g u l a r or c u m u l a t i v e e f f e c t , or an a g i n g f a c t o r a s s o c i a t e d w i t h the appearance of the l a t e r a l d i f f e r e n t i a l . A f i n e r - g r a i n e d , l o n g -term l o n g i t u d i n a l s t u d y might shed more l i g h t on t h e s e p o s s i b i l i t i e s . The MRC I n s t i t u t e of H e a r i n g Research (1981) study found t h a t s i g n i f i c a n t l y more r i g h t - h a n d e d than l e f t - h a n d e d p e o p l e r e p o r t e d t i n n i t u s (17.9% and 14.8% r e s p e c t i v e l y ) . The a u t h o r s p o i n t e d out t h a t t h i s e f f e c t may be confounded w i t h a tendency f o r p r o b a b i l i t y of r i g h t - h a n d e d n e s s t o i n c r e a s e w i t h age ( F l e m i n g e r , D a l t o n , & Standage, 1977). The MRC study a l s o found t h a t the p r e v a l e n c e of t i n n i t u s i n c r e a s e d w i t h i n c r e a s i n g age. W h i l e 14.5% of the sample under 40 y e a r s r e p o r t e d t i n n i t u s , t h i s i n c r e a s e d t o 22.2% of the age group above 60 y e a r s . H i n c h c l i f f e (1961) found a s i m i l a r t r e n d w i t h a g i n g i n h i s sample drawn from a r u r a l p o p u l a t i o n . Reed (1960), w o r k i n g w i t h a c l i n i c a l sample, found comparable p r e v a l e n c e s and r e p o r t e d t h a t t i n n i t u s was most p r e v a l e n t between the ages of about 50 and 75 y e a r s . The c l i n i c a l sample i n H a z e l l ' s (1981a) study had a modal p r e v a l e n c e i n the 50 t o 60 year range. There a r e l i m i t e d d a t a on the p r e v a l e n c e of t i n n i t u s and gender. From a survey of members of a t i n n i t u s s e l f - h e l p group i t was found t h a t the mean ages of onset f o r males was 51.9 y e a r s (s.d.=9.3 y e a r s ) and f o r females 44.9 y e a r s (s.d.=l5.3 y e a r s ) w i t h range ( a c r o s s both sexes) 9-73 y e a r s ( T y l e r & Baker, 35 u n d a t e d ) . These r e s u l t s s h o u l d be i n t e r p r e t e d w i t h c a u t i o n s i n c e these s u b j e c t s might not be r e p r e s e n t a t i v e of t i n n i t e u r s i n g e n e r a l . T i n n i t u s has been found t o occur w i t h a p p r o x i m a t e l y e q u a l p r e v a l e n c e i n males and females i n the g e n e r a l p o p u l a t i o n (MRC I n s t i t u t e of H e a r i n g R e s e a r c h , 1981). A c l i n i c a l sample of p a t i e n t s whose p r i m a r y symptom was t i n n i t u s was s i m i l a r i l y found t o have e q u a l p r o p o r t i o n s of males and females ( H a z e l l , 1981a). As might be e x p e c t e d , g i v e n the preponderance of males exposed t o h i g h l e v e l s of n o i s e i n t h e i r o c c u p a t i o n s , H a l l a m , Rachman, & H i n c h c l i f f e found t h a t t h e i r m e d i c o - l e g a l c l a i m group was e n t i r e l y male. E. F a c t o r s I n f l u e n c i n g Onset and D i s t r e s s L e v e l s S i n c e the mechanism by which t i n n i t u s sounds a r e produced i s not w e l l u n d e r s t o o d , a d i s c u s s i o n of the e t i o l o g y of t h i s symptom must, f o r the most p a r t , be t e n t a t i v e . C o n f i d e n t s p e c i f i c a t i o n of e t i o l o g y of t i n n i t u s i n p a r t i c u l a r c a s e s i s r e l a t i v e l y r a r e and f o r the m a j o r i t y of cases the cause i s not known (McFadden, 1982). T h i s has i m p l i c a t i o n s i n the approach t o t r e a t m e n t which f o r most c a s e s l a r g e l y c o n s i s t s of r e l i e v i n g d i s t r e s s caused by the symptom. McFadden (1982) d e f i n e s " u n e q u i v o c a l s o u r c e s of t i n n i t u s " as f r e q u e n t synchronous o c c u r r e n c e s of t i n n i t u s and i t s cause; or d i s a p p e a r a n c e of t i n n i t u s f o l l o w i n g removal of the c a u s a t o r y agent or t r e a t m e n t of i t s e f f e c t s . Examples of u n e q u i v o c a l s o u r c e s are s e v e r e blows t o the head ( S h u c a r t & Tenner, 1981); o t o t o x i c drugs 36 i n c l u d i n g a n e s t h e t i c s (Brown e t a l . , 1981); i m m o b i l i z a t i o n of the m i d d l e - e a r s t r u c t u r e s caused by o t o s c l e r o s i s , impacted cerumen; and a nomalies of the v a s c u l a t u r e or m u s c u l a t u r e of the head, neck, and jaw (McFadden, 1982). In the H a z e l l , Wood, et a l . (1985) study the c a u s a l e t i o l o g y was deemed unknown i n 44% of 472 c a s e s of t i n n i t u s . Of the o t h e r causes c o n s i d e r e d (e.g. d r u g s , M e n i e r e ' s d i s o r d e r , o t i t i s , o t o s c l e r o s i s ) most f e l l w i t h a 2% t o 6% p r e v a l e n c e range w i t h n o i s e - i n d u c e d h e a r i n g l o s s and a c o u s t i c trauma the cause of 27% of c a s e s of t i n n i t u s . T i n n i t u s d i s t r e s s has been a n a l y s e d i n a f a c t o r a n a l y t i c study by J a k e s , H a l l a m , Chambers, & H i n c h c l i f f e (1985) on 82 p a t i e n t s w i t h t i n n i t u s as the p r e s e n t i n g problem. The f a c t o r a n a l y s i s was conducted on s e l f - r a t e d c o m p l a i n t s about t i n n i t u s and r e l a t e d symptoms, and a u d i o l o g i c a l measurements of t i n n i t u s i n t e n s i t y . Two g e n e r a l t i n n i t u s c o m p l a i n t f a c t o r s emerged: i n t r u s i v e n e s s of t i n n i t u s , and d i s t r e s s due t o t i n n i t u s . These seemed t o r e f e r t o s e n s o r y and a f f e c t i v e components of the d a t a . I t i s s i g n i f i c a n t t h a t t h r e e s e p a r a t e and s p e c i f i c t i n n i t u s c o m p l a i n t f a c t o r s were found: s l e e p d i s t u r b a n c e , m e d i c a t i o n use, and i n t e r f e r e n c e w i t h p a s s i v e a u d i t o r y e n t e r t a i n m e n t s . A u d i o l o g i c a l measurements d i d not l o a d on these f a c t o r s . These f i n d i n g s i n d i c a t e d t h a t c o m p l a i n t s about t i n n i t u s a r e not u n i d i m e n s i o n a l ( i . e . t i n n i t u s i s not o n l y more or l e s s d i s t r e s s i n g ) but r a t h e r m u l t i d i m e n s i o n a l . S i m i l a r r e s u l t s have been r e p o r t e d f o r p a i n c o m p l a i n t s ( C r o c k e t t , P r k a c h i n & C r a i g , 1977). 37 C l e a r e t i o l o g i e s have not been e s t a b l i s h e d f o r most i n s t a n c e s of t i n n i t u s and t h e r e f o r e a good h e u r i s t i c t o adopt might be one i n which o p e r a t i o n a l l y d e f i n e d and l o g i c a l l y c o h e r e n t g r o u p i n g s a r e formed, f e d by an i n f o r m a t i o n base w i d e l y d i s p e r s e d t h r o u g h the d i s c i p l i n e s of o t o l a r y n g o l o g y , a u d i o l o g y , s u r g e r y and, more r e c e n t l y , p s y c h o l o g y . Evans (1981, p.232) has proposed a u s e f u l framework f o r c o n s i d e r i n g f a c t o r s a s s o c i a t e d w i t h the presence of t i n n i t u s . He l i s t e d f o u r groups: p r e d i s p o s i n g f a c t o r s , r e v e a l i n g f a c t o r s , e x a c e r b a t i n g f a c t o r s , and u n a s s o c i a t e d f a c t o r s and gave examples f o r each but d i d not d e f i n e the f a c t o r s r i g o r o u s l y . D e f i n i t i o n s a r e proposed i n the en s u i n g pages f o r t h r e e of the s e g r o u p i n g s but the c o n t e n t and u s e f u l n e s s of the " u n a s s o c i a t e d f a c t o r s " g r o u p i n g i s not c l e a r and i t w i l l not be i n c l u d e d h e r e . a. P r e d i s p o s i n g F a c t o r s . Among " p r e d i s p o s i n g f a c t o r s " a re n o i s e , age, use of t o x i c d r u g s , m i d d l e - e a r problems, head i n j u r y , and more g e n e r a l somatic d y s f u n c t i o n i n c l u d i n g t h y r o i d problems, anaemia and h y p e r t e n s i o n . When thes e f a c t o r s a re p r e s e n t , they may c o n t r i b u t e t o the o c c u r r e n c e of t i n n i t u s . For the purpose of t h i s t h e s i s a p r e d i s p o s i n g f a c t o r i s d e f i n e d as f o l l o w s : a f a c t o r whose presence i s a s s o c i a t e d w i t h an i n c r e a s e d p r o b a b i l i t y of t i n n i t u s but whose absence does not p r e c l u d e the p o s s i b i l i t y of t i n n i t u s . An example of a p r e d i s p o s i n g f a c t o r i s the o c c u r r e n c e of u n i l a t e r a l tumours of the e i g h t h n e r v e , a d i s e a s e s t a t e accompanied by t i n n i t u s i n 83% of 500 p a t i e n t s d e s c r i b e d by Brackman (1981) and i n 92% of R o n i s ' s sample 38 (1981). However, s u r g i c a l removal of the tumour improved the t i n n i t u s i n o n l y about h a l f of the c a s e s . There i s some e v i d e n c e f o r the presence of t i n n i t u s i n n o n - h e a r i n g - r e l a t e d d i s o r d e r s . M u l t i p l e s c l e r o s i s p a t i e n t s may have an i n c r e a s e d p r e v a l e n c e of t i n n i t u s ( S c h l e u n i n g , 1981; S h u c a r t & Tenner, 1981) but the e v i d e n c e f o r t h i s i s not v e r y s t r o n g . S c h l e u n i n g (1981) suggested t h a t c e r t a i n m e t a b o l i c d i s o r d e r s might be a s s o c i a t e d w i t h t i n n i t u s : h y p e r t e n s i o n , h y p o t h y r o i d i s m , and d i a b e t e s . Extreme p h y s i c a l e x e r t i o n and e n v i r o n m e n t a l p r e s s u r e changes have been r e p o r t e d t o have caused t i n n i t u s i n a s m a l l s e r i e s of case h i s t o r i e s ( K a t s a r k a s & B a x t e r , 1976). Exposure t o o c c u p a t i o n a l n o i s e has been found t o be a s s o c i a t e d w i t h i n c r e a s e d o c c u r r e n c e of t i n n i t u s by both the MRC I n s t i t u t e of H e a r i n g Research survey (1981), and H i n c h c l i f f e (1961). The former s t u d y found t h a t the p r e v a l e n c e of t i n n i t u s i n c r e a s e d from 14.4% i n the "no n o i s e " group t o 24.0% i n the " n o i s e " group. These groups were d e f i n e d by t i n n i t e u r s r e p l y i n g n e g a t i v e l y or p o s i t i v e l y t o the q u e s t i o n : "Have you ever worked i n a p l a c e f o r more than s i x months where you had t o r a i s e your v o i c e t o be h e a r d ? " . However, H i n c h c l i f f e (1961), u s i n g a s i m i l a r c r i t e r i o n f o r o c c u p a t i o n a l n o i s e exposure but f o r a p e r i o d of more than a y e a r , found no c o r r e l a t i o n between presence of t i n n i t u s and n o i s e exposure. No o b j e c t i v e measurements of o c c u p a t i o n a l e n v i r o n m e n t a l n o i s e were made i n t h e s e s t u d i e s . U n t i l such measurements are i n c l u d e d i n f u t u r e s t u d i e s , no c o n f i d e n t c o n c l u s i o n can be reached about the 39 a s s o c i a t i o n between t i n n i t u s and o c c u p a t i o n a l n o i s e . H a z e l l (1981b) found t h a t 55% of h i s sample of o t o l a r y n g o l o g i c a l c l i n i c p a t i e n t s w i t h t i n n i t u s as the p r i m a r y symptom, r e p o r t e d some exposure t o n o i s e w i t h 17% h a v i n g had " s i g n i f i c a n t " n o i s e exposure (e.g. u n p r o t e c t e d exposure t o l o u d i n d u s t r i a l or t o f i r e a r m n o i s e ) . b. R e v e a l i n g F a c t o r s . Evans (1981, p.232) proposed a second c a t e g o r y termed " r e v e a l i n g f a c t o r s " which has been d e f i n e d f o r the purposes of t h i s t h e s i s as h a v i n g the a t t r i b u t e of c h a n g i n g an i n d i v i d u a l ' s f o c u s on p r e - e x i s t i n g t i n n i t u s from b e i n g unaware t o b e i n g aware of i t . Examples of r e v e a l i n g f a c t o r s s u p p l i e d by him a r e a u d i o m e t r i c t e s t i n g , l i f e c r i s e s , and s l e e p d i s t u r b a n c e . Other i n s t a n c e s g l e a n e d from the l i t e r a t u r e f o l l o w . The H a l l a m , Rachman, & H i n c h c l i f f e s t u d y of 80 t i n n i t e u r s r e p o r t e d two c a s e s f o r which onset of t i n n i t u s o c c u r r e d d u r i n g or i m m e d i a t e l y a f t e r v i e w i n g a T.V. programme on t i n n i t u s . They a l s o r e p o r t e d t h a t , f o r a s e r i e s of t i n n i t e u r s a t t e n d i n g an ear c l i n i c , onset of t i n n i t u s was a s s o c i a t e d t o v a r y i n g degrees w i t h the o c c u r r e n c e of s t r e s s f u l l i f e e v e n t s . F i f t y p e r c e n t of the s o - c a l l e d p s y c h o g e n i c group i n t h e i r s t u d y r e p o r t e d some p s y c h o l o g i c a l s t r e s s o r a t onset of t i n n i t u s . T h i s was by f a r the h i g h e s t p r o p o r t i o n of any group r e p o r t i n g t h i s . In c o n t r a s t , the m e d i c o - l e g a l group had a r a t e of o n l y 6%. T h i s s uggested t h a t t i n n i t u s symptom r e p o r t i n g was l i n k e d , a t l e a s t f o r some t i n n i t e u r s , w i t h a p r e c i p i t a t i n g s t r e s s o r . 40 S t a c e y (1978) d e s c r i b e d how, w h i l e f i t t i n g a deaf p a t i e n t w i t h a h e a r i n g a i d , she became aware of t i n n i t u s i n the f i t t e d ear f o r the f i r s t time i n her l i f e . She termed t h i s " l a t e n t t i n n i t u s " and e x p r e s s e d c o n c e r n t h a t the p r o c e d u r e of f i t t i n g a i d s c o u l d cause t i n n i t u s t o become p a t e n t . H e l l e r & Bergman (1953) e x p l a i n e d t h a t the reason why 94% of a sample of n o r m a l l y - h e a r i n g , h e a l t h y a d u l t s heard ear sounds o n l y when p l a c e d i n sound-proof chamber was t h a t " s u b a u d i b l e " ear sounds were c o n s t a n t l y b e i n g masked by ambient n o i s e . Removal of ambient n o i s e thus can f u n c t i o n as a r e v e a l i n g f a c t o r . These examples seem t o c o v e r e v e n t s of two t y p e s : f i r s t l y t hose which b r i n g a p r e - e x i s t i n g t i n n i t u s i n t o awareness e.g. a u d i o m e t r i c e x a m i n a t i o n or d i a g n o s t i c q u e s t i o n i n g ; and s e c o n d l y t r a u m a t i c e v e n t s e.g. d e a t h of a spouse ( H a z e l l , 1981c, p233), or r e s u l t s of a c o l d ( W i l s o n & S u t t o n , 1981, p99). However t h e r e i s no p u b l i s h e d r e s e a r c h t o document the c o u r s e of the " r e v e a l e d t i n n i t u s . " c. E x a c e r b a t i n g F a c t o r s . An e x a c e r b a t i n g f a c t o r i s taken t o mean one whose presence i s a s s o c i a t e d w i t h i n c r e a s e d d i s t r e s s from t i n n i t u s . E x a c e r b a t i n g f a c t o r s a r e n e i t h e r s u f f i c i e n t nor n e c e s s a r y f o r t i n n i t u s t o o c c u r . Examples of e x a c e r b a t i n g f a c t o r s t h a t have been suggested i n the l i t e r a t u r e a r e : p s y c h o l o g i c a l f a c t o r s such as a f f e c t , a t t e n t i o n a l f o c u s , and a r o u s a l ; c h e m i c a l f a c t o r s such as n i c o t i n e use and i n g e s t i o n of c e r t a i n m e d i c a t i o n s ; and d i e t a r y f a c t o r s such as s a l t or c a f f e i n e i n t a k e and food 41 a d d i t i v e s . At t h i s t i m e , the l i n k between most of t h e s e and t i n n i t u s i s s p e c u l a t i v e and a n e c d o t a l , a l t h o u g h case study e v i d e n c e s u g g e s t s t h a t they a r e worth c o n s i d e r i n g as c o n t r i b u t o r y t o the e t i o l o g y of t i n n i t u s . In view of the s c a n t i n f o r m a t i o n on e x a c e r b a t i n g f a c t o r s i n the t i n n i t u s l i t e r a t u r e , r e s e a r c h from r e l a t e d f i e l d s was examined. Pennebaker (1982) made a p i o n e e r i n g s t e p by i n t e g r a t i n g l i t e r a t u r e on p s y c h o l o g i c a l mechanisms r e l a t e d t o p h y s i c a l symptoms and by p r o v i d i n g a framework w i t h i n which the p e r c e p t i o n of these symptoms can be c o n s i d e r e d . He d i s t i n g u i s h e d between p a i n and non-pain symptoms and f o c u s s e d on the l a t t e r . T i n n i t u s c o u l d be c o n s i d e r e d t o be a non-pain symptom. The c o n s i d e r a t i o n of c o g n i t i v e f a c t o r s was i m p o r t a n t from h i s a n a l y s i s and t h e s e p o t e n t i a l l y have r e l e v a n c e f o r t i n n i t u s r e s e a r c h . The r e s e a r c h on p s y c h o l o g i c a l c o n c o m i t a n t s of p a i n on the one hand, and of a v e r s i v e non-pain s t i m u l i ( p a r t i c u l a r l y n o i s e ) on the o t h e r , w i l l be b r i e f l y s u r v e y e d . The p a i n l i t e r a t u r e i s g e n e r a l l y r i c h i n d e s c r i b i n g p s y c h o l o g i c a l f a c t o r s which i n f l u e n c e the e x p e r i e n c e of p a i n . Turk, Meichenbaum, & Genest (1983) r e v i e w e d p s y c h o l o g i c a l and o t h e r i n f l u e n c e s on p a i n such as e a r l y p a i n e x p e r i e n c e s , s o c i o -c u l t u r a l background, and a n x i e t y s u r r o u n d i n g n o x i o u s s t i m u l a t i o n . They c o n c l u d e d t h a t p a i n e x p e r i e n c e c o u l d not be a d e q u a t e l y a c c o u n t e d f o r by s e n s o r y and p h y s i o l o g i c a l t h e o r i e s but r a t h e r i t was a s u b j e c t i v e e x p e r i e n c e i n v o l v i n g o t h e r f a c t o r s as w e l l . In e s s e n c e , an adequate c o n c e p t u a l i z a t i o n of 42 p a i n s h o u l d be m u l t i - d i m e n s i o n a l i n c o r p o r a t i n g c o g n i t i v e and a f f e c t i v e a s p e c t s w i t h p h y s i c a l s t i m u l i and s e n s o r y p h y s i o l o g y ( p . 8 1 ) . C o n s i d e r a t i o n of t h e s e might p r o v i d e v a l u a b l e i n f o r m a t i o n f o r u n d e r s t a n d i n g t i n n i t u s d i s t r e s s and suggest a n a l o g u e s f o r r e s e a r c h t h a t needs t o be done. House and Brackmann (1981) suggested t h a t t i n n i t u s might be s i m i l a r t o p a i n i n some r e s p e c t s . Both a r e s u b j e c t i v e phenomena and f a c t o r s which i n f l u e n c e p a i n s e v e r i t y , such as a n x i e t y l e v e l , a l s o appear t o a f f e c t the d i s t r e s s a s s o c i a t e d w i t h t i n n i t u s . 1. C o g n i t i v e f a c t o r s - c o n t r o l C o g n i t i v e f a c t o r s have been demonstrated t o p l a y an i m p o r t a n t r o l e i n the response of s u b j e c t s t o p a i n . For example K a n f e r and G o l d f o o t (1966) and K a n f e r and S e i d n e r (1973) found t h a t , when exposed t o c o l d p r e s s o r p a i n , s u b j e c t s who had c o n t r o l over the n o x i o u s s t i m u l i c o u l d use s e l f - c o n t r o l t e c h n i q u e s more e f f e c t i v e l y than th o s e who had no c o n t r o l over s t i m u l i . The more s t r o n g l y s u b j e c t s b e l i e v e d i n the u s e f u l n e s s of c o p i n g s t r a t e g i e s , the more e f f e c t i v e was the s t r a t e g y . In a l a b o r a t o r y s e t t i n g , Bowers (1968) found t h a t s u b j e c t s who were t o l d t h a t shocks were t o be a d m i n i s t e r e d t o them on a random s c h e d u l e , had lower p a i n t h r e s h o l d s than those who were t o l d t h a t they were a b l e t o a v o i d shocks i n the e x p e r i m e n t . T h i s suggested t h a t l a c k of c o n t r o l over a p a i n f u l s t i m u l u s l e d t o h i g h e r l e v e l s of p e r c e i v e d p a i n . In a r e l a t e d experiment J o n e s , B e n t l e r , and P e t r y (1966) found t h a t i n f o r m a t i o n r e d u c i n g 43 the degree of u n c e r t a i n t y about r e c e i p t of e l e c t r i c shocks s e r v e d as a s t r o n g p o s i t i v e r e i n f o r c e m e n t f o r most s u b j e c t s . The a u t h o r s t h e o r i z e d t h a t the r e d u c t i o n of u n c e r t a i n t y about the s c h e d u l i n g of a v e r s i v e s t i m u l i p e r m i t t e d s u b j e c t s t o make responses which m i n i m i z e d p a i n and a n x i e t y . In t h e case of c h r o n i c p a i n p a t i e n t s , the amount of p e r c e i v e d c o n t r o l t h a t c h r o n i c p a i n s u f f e r e r s f e e l may be an impor t a n t f a c t o r i n d e t e r m i n i n g how they cope w i t h p a i n (Weisenberg, 1984). R o s k i e s & L a z a r u s (1980) have suggested t h a t how a person copes i n g e n e r a l , i s dependent on a p p r a i s a l of the t h r e a t i n v o l v e d , p e r c e i v e d consequences of the t h r e a t , and p e r s o n a l r e s o u r c e s a v a i l a b l e t o cope. Thus, b e l i e f s about symptoms ( i n c l u d i n g p a i n and t i n n i t u s ) and p e r c e p t i o n of p e r s o n a l c o n t r o l over them may i m p o r t a n t l y d e t e r m i n e a b i l i t y t o cope ( G i r o d o & Wood, 1977). The r e s e a r c h on a v e r s i v e (but non-pain) s t i m u l i would a l s o appear t o be of r e l e v a n c e t o t i n n i t u s r e s e a r c h . An analogue study by Corah and B o f f a (1970) i n v e s t i g a t e d the e f f e c t s of a l l o w i n g some n o r m a l - h e a r i n g s u b j e c t s the o p p o r t u n i t y of t u r n i n g o f f the sound of a v e r s i v e w h i t e n o i s e . Another group d i d not have t h i s c h o i c e . Both s e l f - r a t i n g s of d i s c o m f o r t and measurement of s k i n conductance showed t h a t s u b j e c t s who were g i v e n the c h o i c e f e l t l e s s d i s c o m f o r t than those who were not. The a u t h o r s c o n c l u d e d t h a t the sense of c o n t r o l a f f o r d e d by the c h o i c e was an impo r t a n t d e t e r m i n a n t of the c o g n i t i v e a p p r a i s a l of the a v e r s i v e s t i m u l u s . 44 In r e s e a r c h more c l o s e l y r e l a t e d t o c l i n i c a l symptoms, Pennebaker, Burnam, S c h a e f f e r , and Harper (1977) found t h a t s u b j e c t s who had l i t t l e c o n t r o l over the t e r m i n a t i o n of b l a s t s of w h i t e n o i s e , r e p o r t e d a h i g h e r i n c i d e n c e of p h y s i c a l symptoms than s u b j e c t s who were a l l o w e d t o c o n t r o l the n o i s e . In the broader c o n t e x t of e n v i r o n m e n t a l n o i s e , G l a s s and S i n g e r (1972) have shown t h a t , over the l o n g e r term, u n c o n t r o l l a b l e e n v i r o n m e n t a l n o i s e c o u l d have such n e g a t i v e consequences as l owered t o l e r a n c e f o r f r u s t r a t i o n and reduced p e r s i s t e n c e i n c o m p l e t i n g a s s i g n e d t a s k s . U n t r e a t e d t i n n i t e u r s who a r e e x p e r i e n c i n g d i s t r e s s r e p o r t t h a t they b e l i e v e they have no c o n t r o l over t h e i r t i n n i t u s and t h a t t h i s i s e x t r e m e l y d i s t u r b i n g t o them. 2. C o g n i t i v e f a c t o r s - a t t e n t i o n a l f o c u s I t i s e v i d e n t t h a t f o r a p e r s o n t o be aware of a p h y s i c a l symptom, he or she must have d i r e c t e d a t t e n t i o n t o the s e n s a t i o n a s s o c i a t e d w i t h the symptom. I t i s l i k e l y t h a t e n v i r o n m e n t a l v a r i a b l e s which f o c u s a t t e n t i o n on the body would te n d t o i n c r e a s e the p e r c e i v e d i n t e n s i t y of symptoms, and t h a t t h o s e which d i s t r a c t a t t e n t i o n would te n d t o d e c r e a s e the p e r c e i v e d i n t e n s i t y (Pennebaker and S k e l t o n , 1978). Promoting a t t e n t i o n a l f o c u s on p a i n has been shown t o d e c r e a s e p a i n t o l e r a n c e as measured by the time s u b j e c t s were a b l e t o endure c o l d - p r e s s o r p a i n (Kanfer and G o l d f o o t , 1966). A l s o , when s u b j e c t s were t o l d t o watch the m i r r o r - i m a g e of t h e i r hand submerged i n c o l d water, the p a i n t h r e s h o l d was found t o 45 have been lowered when compared t o a d i s t r a c t i o n t a s k group. B l i t z and D i n n e r s t e i n (1971) c o n c l u d e d t h a t a t t e n t i o n a l mechanisms p l a y e d an i m p o r t a n t r o l e i n d e t e r m i n i n g p a i n t h r e s h o l d s i n a c o l d p r e s s o r t a s k . The group of s u b j e c t s which was i n s t r u c t e d t o f o c u s on the c o l d a s p e c t of the s t i m u l u s and t o d i s s o c i a t e i t from the p a i n f e l t , as w e l l as the group asked t o i n t e r p r e t i t as p l e a s a n t , b o t h e x p e r i e n c e d s i g n i f i c a n t e l e v a t i o n s i n p a i n t h r e s h o l d s when compared t o a c o n t r o l group. Other c o g n i t i v e f a c t o r s which have been a s s o c i a t e d w i t h reduced t o l e r a n c e t o p a i n i n c l u d e r e d u c t i o n of p e r c e i v e d c o n t r o l over n o x i o u s s t i m u l u s , l a c k of c o g n i t i o n s t o a t t e n u a t e i n t e n s i t y (Weisenberg, 1977); p e r c e i v e d l a c k of s e l f - e f f i c a c y i n c o n t r o l l i n g p a i n and the presence of c a t a s t o p h i z i n g c o g n i t i o n s ( R o s e n s t i e l & Ke e f e , 1983); the reduced p e r c e i v e d a b i l i t y by s u b j e c t s t o c o n t r o l parameters of p a i n f u l s t i m u l i (Staub, T u r s k e y , and S c h w a r t z , 1971). Once a g a i n , i t remains t o be e s t a b l i s h e d whether t h e s e r e s u l t s can be g e n e r a l i z e d t o t i n n i t u s as the t a r g e t symptom. 3. C o g n i t i v e s e t and i n f o r m a t i o n a l f a c t o r s I t has been found t h a t a s t i m u l u s i n t r i n s i c a l y n e u t r a l on the p a i n - p l e a s u r e continuum ( m e c h a n i c a l v i b r a t i o n s a p p l i e d t o a f i n g e r t i p ) c o u l d be i n t e r p r e t e d as h a v i n g e i t h e r a p o s i t i v e v a l e n c e ( p l e a s u r a b l e ) or a n e g a t i v e v a l e n c e ( p a i n f u l ) depending on the p r i o r s e t o f f e r e d t o s u b j e c t s by v e r b a l i n f o r m a t i o n (Pennebaker and S k e l t o n , 1978). T h i s s t u d y i n d i c a t e d t h a t e x p e c t a t i o n s r e g a r d i n g a n e u t r a l s t i m u l u s can be m a n i p u l a t e d . 46 In e x t e n d i n g t h i s b a s i c r e s e a r c h t o somatic symptoms, Pennebaker and S k e l t o n (1978) found t h a t when a n e g a t i v e s e t was induced f o r a symptom, n a s a l c o n g e s t i o n , a l r e a d y p r e s e n t i n norma l s , t h i s r e s u l t e d i n i n c r e a s e s i n r e p o r t e d symptom s e v e r i t y . When s u b j e c t s were t o r a t e n a s a l c o n g e s t i o n a f t e r b e i n g asked t o a t t e n d e i t h e r t o " d i s r u p t i o n and b l o c k a g e " of n a s a l passages or t o " f r e e passage of a i r " , the l a t t e r group gave a lower r a t i n g of c o n g e s t i o n . The a u t h o r s c o n c l u d e d t h a t f o r p a i n f u l symptoms t h e r e i s a b u i l t - i n n e g a t i v e i n t e r p r e t a t i o n . "For n o n p a i n f u l symptoms, however, the i n t e r p r e t i v e c o n t e x t d e t e r m i n e s whether the e x p e r i e n c e d s e n s a t i o n s a r e d e f i n e d as symptomatic a t a l l (p. 528). Research has r e c e n t l y been f o c u s s e d on a b e t t e r u n d e r s t a n d i n g of how symptomatic peop l e i n t e r p r e t symptoms and at t e m p t s have been made t o c o n s t r u c t models which d e s c r i b e c o g n i t i v e p r o c e s s e s and s t r u c t u r e s i n t h i s r e g a r d (Mechanic, 1976; L e v e n t h a l , Meyer, and Nerenz, 1980; Pennebaker, 1982). I t i s l i k e l y t h a t c e r t a i n schemata of p a i n s u f f e r e r s f o r i n t e r p r e t i n g , m o n i t o r i n g , and r e a c t i n g t o symptoms a f f e c t t h e a c t i o n they t a k e t o o b t a i n r e l i e f ( P i n s k y , 1979). T i n n i t e u r s may respond s i m i l a r l y t o t i n n i t u s as p a i n s u f f e r e r s respond t o t h e i r symptom. In the realm of the t i n n i t u s symptom and i t s e v a l u a t i o n by s u f f e r e r s , the q u e s t i o n a r i s e s how the i n f o r m a t i o n about t i n n i t u s , i n i t i a l l y s u p p l i e d t o t i n n i t e u r s by h e a l t h c a r e p r o f e s s i o n a l s , i n f l u e n c e s f u t u r e d i s t r e s s and a t t i t u d e s t o t i n n i t u s . T h i s q u e s t i o n has i m p o r t a n t i m p l i c a t i o n s f o r the p s y c h o l o g i c a l management of t i n n i t e u r s as i t would i n d i c a t e how 47 c l e a r i n f o r m a t i o n about- the i m p l i c a t i o n s of h a v i n g t i n n i t u s might be an i m p o r t a n t i n h i b i t o r of a n e g a t i v e i d e a t i o n s p i r a l and a c c e l e r a t i n g d i s t r e s s . On the o t h e r hand, i t i s l i k e l y t h a t t i n n i t e u r s w i t h g e n e r a l l y p o s i t i v e a t t i t u d e s (whether spontaneous or a s s i s t e d ) would t e n d t o f e e l l e s s d i s t r e s s e d over time than s u f f e r e r s w i t h unfounded n e g a t i v e b e l i e f s , a l l o t h e r c i r c u m s t a n c e s r e m a i n i n g the same. T h i s b e i n g the c a s e , an e a r l y p romotion of p o s i t i v e a t t i t u d e s might produce ongoing d i v i d e n d s . I t i s i m p o r t a n t t o know whether g e n e r a l i z a t i o n of e f f e c t a c r o s s p h y s i o l o g i c a l systems ( e . g . d i g e s t i v e and r e s p i r a t o r y ) i s v a l i d and whether d i f f e r e n t systems a r e s u b j e c t t o the same p s y c h o l o g i c a l p r o c e s s e s . Pennebaker (1977) found t h a t m a n i p u l a t i o n of a t t e n t i o n a l f o c u s produced s i m i l a r r e s u l t s f o r n a s a l c o n g e s t i o n , c o l d - p r e s s o r p a i n , and muscle f a t i g u e . T h i s s u g g e sted t h a t a t e c h n i q u e t h a t a f f e c t e d one symptom would l i k e l y change the p e r c e p t i o n of the n o n - t a r g e t symptoms. 4. A f f e c t i v e f a c t o r s P a i n can be e x a c e r b a t e d or a t t e n u a t e d by a f f e c t i v e p r o c e s s e s ( C r a i g , 1984). I n c r e a s e d e m o t i o n a l d i s t r e s s has been a s s o c i a t e d w i t h h e i g h t e n e d a n t i c i p a t i o n and v i g i l a n c e of p a i n , and i n c r e a s e d m o n i t o r i n g of p a i n ( C r a i g , 1984). Horan & D e l l i n g e r (1974) have r e p o r t e d t h a t f o r e x p e r i m e n t a l l y induced p a i n , when s u b j e c t s were engaged i n p o s i t i v e emotive imagery, p a i n t o l e r a n c e i n c r e a s e d . On the o t h e r hand when a n x i e t y was i n c r e a s e d by e x p e r i m e n t a l m a n i p u l a t i o n , p a i n t o l e r a n c e was reduced ( N i s b e t t and S c h a c t e r , 1966). I t has been r e p o r t e d i n 48 r e s e a r c h on c h r o n i c low back p a i n p a t i e n t s , t h a t d y s p h o r i c a f f e c t was a s s o c i a t e d w i t h d y s f u n c t i o n a l c o g n i t i v e a p p r a i s a l and m a l a d a p t i v e c o p i n g s t y l e ( L e f e b v r e , 1981). W h i l e d e p r e s s i o n has commonly been a s s o c i a t e d w i t h c h r o n i c p a i n , r e s e a r c h on the r e l a t i o n s h i p has y i e l d e d u n e q u i v o c a l r e s u l t s . P i l o w s k y , Chapman, and B o n i c a (1977) found t h a t o n l y about 10% of c h r o n i c p a i n p a t i e n t s were d e p r e s s e d whereas o t h e r s ( e . g . L i n d s e y and Wykoff, 1981) have e s t i m a t e s as h i g h as 85%. In r e v i e w i n g r e s e a r c h on d e p r e s s i o n and p a i n , Romano & Turner (1985) found t h a t , because many s t u d i e s were i n a d e q u a t e l y c o n t r o l l e d , i t c o u l d not be c o n c l u d e d t h a t d e p r e s s i o n was more p r e v a l e n t i n c h r o n i c p a i n p a t i e n t s than i n comparable c o n t r o l p o p u l a t i o n s . Rachman & Hodgson (1974) c h a r a c t e r i z e d a f f e c t as a l o o s e l y c o u p l e d , p a r t i a l l y i ndependent, system t h a t i n t e r a c t e d w i t h c o g n i t i v e , b e h a v i o u r a l , and p h y s i o l o g i c a l p r o c e s s e s . In the case of p a i n , i t has been suggested t h a t i t was im p o r t a n t t o r e c o g n i z e the independent and i n t e r a c t i v e f u n c t i o n i n g of t h e s e systems s i n c e they may or may not c o v a r y ( L e v e n t h a l & E v e r h a r t , 1979, Melzack & W a l l , 1983). No r e s e a r c h i n v e s t i g a t i n g the r e l a t i o n s h i p between t i n n i t u s and a f f e c t has been r e p o r t e d . 5. C i r c a d i a n f a c t o r s I t has been found t h a t some p h y s i o l o g i c a l f u n c t i o n s v a r y a c c o r d i n g t o time of day. H e a l t h y v o l u n t e e r s have been found t o d i s p l a y a c i r c a d i a n rhythm i n t h e i r s e n s i t i v i t y t o e l e c t r i c shock p a i n . As the day p r o g r e s s e d from morning t o e v e n i n g , s e n s i t i v i t y i n c r e a s e d ( P r o c a c c i , 1972). T h i s o b s e r v a t i o n has 49 been r e p e a t e d w i t h c h r o n i c c l i n i c a l p a i n p a t i e n t s . One study r e q u i r e d 54 c l i n i c a l s u b j e c t s w i t h i n t r a c t a b l e p a i n t o monitor and r e c o r d p a i n i n t e n s i t y a t t w o - h o u r l y i n t e r v a l s ( G l y n n , L l o y d , and F o l k a r d , 1976). I t was found t h a t t h e r e was a t r e n d f o r p a i n i n t e n s i t y t o i n c r e a s e from morning t o n i g h t ; and f o r those s u b j e c t s who remained a t home a l l day t o r e p o r t more i n t e n s e p a i n than t h o s e who worked. A thorough s i n g l e - c a s e s t u d y , u s i n g an a l t e r n a t i n g b a s e l i n e d e s i g n t o t r a c k t i n n i t u s , found t h a t f o r the s u b j e c t concerned, c i r c a d i a n rhythms seemed t o be s i m i l a r l y i m p l i c a t e d . The t i n n i t u s was more i n t e n s e a t n i g h t and l e a s t i n t e n s e i n the e a r l y morning ( M a l a t e s t a , S u t k e r , and Adams, 1980). In t h i s s t u d y the s u b j e c t ' s s e l f - r e p o r t of t i n n i t u s i n t e n s i t y c o r r e s p o n d e d w e l l t o a u d i o l o g i c a l l y measured t i n n i t u s i n t e n s i t y . Only 41% of H a z e l l ' s (1981a) h e a r i n g - c l i n i c p a t i e n t s found t h a t time of day was not a s s o c i a t e d w i t h w orsening of the t i n n i t u s . Of the remainder, o n l y 3% r e p o r t e d t h a t a f t e r n o o n was the worst p e r i o d , w i t h morning awakening time and e v e n i n g about e q u a l l y nominated as worst (26% and 29% r e s p e c t i v e l y ) . In the T y l e r and Baker (undated) survey of s e l f - h e l p group members, 16.6% found t h a t t i n n i t u s was more troublesome i n the morning than a t any o t h e r time of the day. From t h i s s l i m e v idence about d i u r n a l f l u c t u a t i o n of t i n n i t u s d i s t r e s s , one might suggest t h a t t i n n i t u s i n t e n s i t y was h i g h e r a t t i m e s of the day w i t h the l e a s t d i s t r a c t i o n . T h i s might be the reason t h a t p e o p l e w i t h i n t r a c t a b l e p a i n who went t o work each day, had 50 lower p a i n i n t e n s i t y r a t i n g s than the comparison group t h a t d i d not ( G l y n n , L l o y d , and F o l k a r d , 1980). What was more, p a i n r a t i n g s by the w o r k i ng group i n the e v e n i n g m a i n t a i n e d a lower l e v e l compared t o the o t h e r group. 6. A r o u s a l In a s t u d y i n which the l e v e l of a r o u s a l of e x p e r i m e n t a l s u b j e c t s was c h e m i c a l l y m a n i p u l a t e d by the a d m i n i s t r a t i o n of c a f f e i n e t o e x p e r i m e n t a l but not t o c o n t r o l s u b j e c t s , Haslam (1967) found t h a t p a i n t h r e s h o l d was s l i g h t l y but s i g n i f i c a n t l y l owered by c a f f e i n e consumption. C o n t r o l s u b j e c t s d i d not show t h i s e f f e c t . U n f o r t u n a t e l y the e x p e r i m e n t a l d e s i g n d i d not p r o v i d e c o n t r o l s u b j e c t s w i t h a comparable but c a f f e i n e - f r e e beverage and t h i s f i n d i n g t h e r e f o r e s h o u l d be i n t e r p r e t e d c a u t i o u s l y . In an ABAB s i n g l e s u b j e c t study M a l a t e s t a , S u t k e r , and Adams (1980) s i m i l a r l y found t h a t the i n t e n s i t y of t i n n i t u s i n c r e a s e d f o r about 45 minutes a f t e r i n g e s t i o n of c a f f e i n e . A f t e r t h i s , t i n n i t u s i n t e n s i t y of t h i s s u b j e c t d e c r e a s e d . Haslam (1967) suggested t h a t the r e l a t i o n s h i p between a r o u s a l and p a i n p e r c e p t i o n might f o l l o w an i n v e r t e d - U f u n c t i o n w i t h h i g h e r p a i n t h r e s h o l d l e v e l s a s s o c i a t e d w i t h what she termed p r o f o u n d a n e s t h e s i a ; d e c r e a s i n g l e v e l s a s s o c i a t e d w i t h n a t u r a l s l e e p through t o normal w a k e f u l n e s s ; and then h i g h e r t h r e s h o l d s a g a i n i n extreme a r o u s a l s t a t e s (e.g. i n m i l i t a r y combat and i n c o n t a c t s p o r t s , where i t i s w e l l known t h a t q u i t e severe i n j u r i e s can go u n n o t i c e d i n the heat of the game). In t h i s c o n t e x t i t i s p o s s i b l e t h a t c a f f e i n e , a s t i m u l a n t t o the 51 c e n t r a l nervous system, might i n c r e a s e a r o u s a l from a normal l e v e l and r e s u l t i n a l owered p a i n t h r e s h o l d ; and, i n the case of t i n n i t u s , p o s s i b l y r e s u l t i n i n c r e a s e d t i n n i t u s i n t e n s i t y . A problem w i t h t h i s h y p o t h e s i s i s t h a t t h e r e i s no method of d e t e r m i n i n g a p r i o r i which p o s i t i o n on the U-curve a g i v e n a r o u s a l s t a t e would occupy. I t s u t i l i t y i s t h e r e f o r e l i m i t e d t o d e s c r i p t i v e and c o n c e p t u a l uses. 7. F a t i g u e F a t i g u e i s r e p o r t e d by t i n n i t e u r s t o be one of the f a c t o r s which i n f l u e n c e t h e i r e x p e r i e n c e of t i n n i t u s and i s t h e r e f o r e of i n t e r e s t i n t h i s p r o j e c t . F a t i g u e has been of i n t e r e s t t o r e s e a r c h e r s i n the f i e l d s of work s t u d y , k i n e s i o l o g y , and p e r c e p t i o n and c o g n i t i v e p s y c h o l o g y and t h e i r a p p l i e d a s p e c t s ( H o l d i n g , 1983). However, i t has not been e x t e n s i v e l y pursued as a f a c t o r a f f e c t i n g d i s o r d e r s i n the m e d i c a l p s y c h o l o g y domain. To examine the p o s s i b i l i t y t h a t f a t i g u e might i n f l u e n c e symptom p e r c e p t i o n of t i n n i t u s , a s e r i e s of 46 f i l e s of g e n e r a l o t b l a r y n g o l o g i c a l p a t i e n t s was a n a l y s e d a t the Vancouver G e n e r a l H o s p i t a l t i n n i t u s c l i n i c . P e r c e n t a g e endorsements of 43%, 27%, 25%, and 5% r e s p e c t i v e l y f o r f e e l i n g t i r e d , t e n s e , r e l a x e d , and a f t e r use of a l c o h o l , were o b t a i n e d on a s u r vey of f a c t o r s which might e x a c e r b a t e t i n n i t u s . A v e r b a l survey of about 50 members of the Vancouver T i n n i t u s S e l f - H e l p Group c o n f i r m e d t h i s f i n d i n g : f a t i g u e and s t r e s s were g i v e n most f r e q u e n t l y as f a c t o r s i n c r e a s i n g d i s t r e s s from t i n n i t u s . 52 P h y s i o l o g i c a l parameters which might be used as cues f o r the p e r c e p t i o n of e f f o r t were reviewed by M i h e v i c (1981). In t h i s t y p e of r e s e a r c h the f o c u s has o f t e n been on p h y s i o l o g i c a l c o r r e l a t e s of e x e r t i o n and f a t i g u e e.g. h e a r t r a t e , oxygen consumption, r e s p i r a t i o n r a t e , and l a c t a t e c o n c e n t r a t i o n . Kinsman, W e i s e r , and Stamper (1973) i d e n t i f i e d by m u l t i d i m e n s i o n a l c l u s t e r a n a l y s i s t h r e e s u b j e c t i v e c l u s t e r s a s s o c i a t e d w i t h s t r e n u o u s b i c y c l e e x e r c i s e : f a t i g u e , t a s k a v e r s i o n , and m o t i v a t i o n . The f a t i g u e d imension c o u l d be f u r t h e r a n a l y s e d i n t o t h r e e components: g e n e r a l f a t i g u e , l e g f a t i g u e , and c a r d i o p u l m o n a r y d i s t r e s s . I t was not c l e a r whether t h i s f i n d i n g c o u l d be extended t o o t h e r forms of p h y s i c a l e x e r c i s e . In summarizing the r e s e a r c h on p h y s i c a l f a t i g u e , H o l d i n g (1983) found t h a t p s y c h o l o g i c a l f a c t o r s such as e x p e c t a n c y and m o t i v a t i o n a f f e c t e d performance. Such c e n t r a l f a c t o r s tended t o o v e r r i d e f a t i g u e i n terms of performance. However, t h e r e was l i k e l y t o be a p o i n t of p e r i p h e r a l e x h a u s t i o n beyond which c o n t i n u i n g performance was e x c e e d i n g l y d i f f i c u l t or i m p o s s i b l e because of the e f f e c t s of a c c u m u l a t i n g l a c t i c a c i d . A f a i r l y c o n s i s t e n t f i n d i n g has been t h a t even under c o n d i t i o n s of extreme p h y s i c a l f a t i g u e , s u b j e c t s were s t i l l a b l e t o p e r f o r m a d e q u a t e l y on motor and c o g n i t i v e t a s k s (Warren and C l a r k , 1937; C h i l e s , 1955). The c o m p l e x i t y of the f a t i g u i n g t a s k was seen as a f a c t o r i n d e t e r m i n i n g performance ( H o l d i n g , 1983). A c t i v i t i e s which 53 i n v o l v e d s i m p l e , r e p e t i t i v e t a s k s g e n e r a l l y r e s u l t e d i n a performance decrement over time (Gagne, 1953). When t a s k s were more complex (and t h e r e f o r e p o s s i b l y more a r o u s i n g ) the e f f e c t on performance was a l s o more complex. Thus M c F a r l a n d (1953) d i d not f i n d c l e a r e v i d e n c e of o p e r a t i o n a l f a t i g u e i n l o n g hours of f l y i n g , and Brown (1967) f a i l e d t o f i n d d e t e r i o r a t i o n i n a v i g i l a n c e t a s k secondary t o a f a t i g u i n g p r o l o n g e d c a r d r i v i n g t a s k . On the c o n t r a r y , v i g i l a n c e s c o r e s improved. He noted t h a t the b e s t assessment of f a t i g u e might be g i v e n by s u b j e c t i v e r a t i n g and not by performance s c o r e s on b e h a v i o u r a l t a s k s . H o l d i n g (1983) d e s c r i b e d the d i f f i c u l t i e s r e s e a r c h e r s i n t h i s f i e l d have e n c o u n t e r e d i n t r y i n g t o d e f i n e f a t i g u e . I t has been o p e r a t i o n a l l y d e f i n e d i n terms of number of hours of s l e e p l o s t , or by the number of hours of f a t i g u i n g work performed. T h i s approach has g e n e r a l l y not been s u c c e s s f u l i n p r e d i c t i n g outcome a t t a s k s subsequent t o f a t i g u e i n d u c t i o n . I t has been found t h a t t a s k demands may w e l l r e s u l t i n normal l e v e l s of performance d e s p i t e the p u r p o r t e d f a t i g u e . I t seems then t h a t d e f i n i n g f a t i g u e s i m p l y by the d u r a t i o n of the f a t i g u i n g t a s k may not be u s e f u l . B a r t l e y and Chute (1947) suggested t h a t t h e r e were t h r e e main e f f e c t s of f a t i g u e : " f a t i g u e p r o p e r " ( s u b j e c t i v e f e e l i n g s of b o d i l y d i s c o m f o r t and a v e r s i o n t o e f f o r t ) , work output (performance d a t a ) , and impairment ( p h y s i o l o g i c a l changes a t the t i s s u e l e v e l ) . H o l d i n g (1983) p o i n t e d out t h a t many s t u d i e s have f a i l e d t o f i n d c o v a r i a t i o n among the s e a s p e c t s of f a t i g u e (e.g. P i e r s o n and 54 R i c h , 1967), whereas fewer r e s u l t s have shown an a s s o c i a t i o n (e.g. Dureman and Boden, 1972). The f a c t o r s i n v o l v e d here appear t o be s i m i l a r t o the components of the t h r e e - s y s t e m s model of f e a r suggested by Lang (1971). He p o s t u l a t e d t h a t " a l l e m o t i o n a l b e h a v i o u r s a r e m u l t i p l e systems - v e r b a l - c o g n i t i v e , motor, and p h y s i o l o g i c a l e v e n t s - t h a t i n t e r a c t through i n t e r o c e p t i v e ( n e u r a l and hormonal) and e x t e r o c e p t i v e c h a n n e l s . A l l systems a r e c o n t r o l l e d or i n f l u e n c e d by b r a i n mechanisms, but the i m p o r t a n t c e n t r e s of i n f l u e n c e ( c o r t i c a l or sub-c o r t i c a l , l i m b i c or b r a i n - s t e m ) are v a r i e d and, l i k e the r e s u l t i n g b e h a v i o u r s , p a r t i a l l y independent" (Lang, 1971, p. 108). The r e l a t i v e l y l o o s e c o u p l i n g among the s e t h r e e systems has been extended t o and i n c o r p o r a t e d i n models of o t h e r a s p e c t s of b e h a v i o u r e.g. the c o g n i t i v e - b e h a v i o u r a l c o n c e p t u a l i z a t i o n of p a i n (Turk, Meichenbaum, and Genest, 1983), and of anger (Novaco, 1981). I t might be h e l p f u l f o r r e s e a r c h e r s t o extend t h i s model t o the study of f a t i g u e . R e s u l t s o b t a i n e d from a p i l o t s tudy (see Appendix A) i n d i c a t e d t h a t i t was f e a s i b l e t o use a number v i g i l a n c e t a s k e x p e r i m e n t a l l y t o induce f a t i g u e i n o r d e r t o i n v e s t i g a t e i t s e f f e c t s on t i n n i t u s . Thus i t i s apparent from c o n s i d e r a b l e r e s e a r c h e v i d e n c e t h a t the presence of symptoms was not the s o l e d e t e r m i n a n t of the l e v e l of d i s t r e s s e x p r e s s e d or the i n t e n s i t y f e l t . R a t h e r , c o g n i t i v e , a f f e c t i v e and o t h e r a s p e c t s of these d i s t r e s s i n g 55 s t a t e s were i m p o r t a n t • f a c t o r s i n d e t e r m i n i n g response t o them. T h i s s e c t i o n , which c o v e r e d what the t i n n i t u s l i t e r a t u r e has termed e x a c e r b a t i n g f a c t o r s , i n d i c a t e s a wide range of p o s s i b l e i n f l u e n c e s on t i n n i t u s d i s t r e s s l a r g e l y u n r e s e a r c h e d t o d a t e . F. Treatment of T i n n i t u s T h i s s t u d y i s not prima f a c i e concerned w i t h t r e a t m e n t outcome f o r t i n n i t u s but i t does have p o t e n t i a l r e l e v a n c e f o r r e s e a r c h i n t h i s a r e a and f o r the d e s i g n of t i n n i t u s t r e a t m e n t programmes. I t was i m p o r t a n t t o r e v i e w the t i n n i t u s t r e a t m e n t l i t e r a t u r e i n o r d e r to p r o v i d e a p e r s p e c t i v e on the r e l a t i v e l a c k of s u c c e s s of these t r e a t m e n t s . A g a i n s t t h i s background, the r a t i o n a l e f o r t h i s s tudy .and i t s f i n d i n g s might assume more c l i n i c a l r e l e v a n c e . T i n n i t u s has proven t o be s i n g u l a r l y d i f f i c u l t t o r e l i e v e f o r the m a j o r i t y of s u f f e r e r s . The c h a l l e n g e t h i s has p r e s e n t e d t o h e a l t h p r o f e s s i o n a l s , and the urgency e x p e r i e n c e d by d i s t r e s s e d t i n n i t e u r s , has r e s u l t e d i n a m u l t i p l i c i t y of t r e a t m e n t methods. Many of them have p e r s i s t e d i n the absence of e m p i r i c a l s u p p o r t . Treatment approaches might be b r o a d l y d i v i d e d i n t o p a s s i v e and a c t i v e t r e a t m e n t s . The former a r e c h a r a c t e r i z e d by the use of a d e v i c e , m e d i c a t i o n , or s u r g e r y t o e l i m i n a t e or reduce the t i n n i t u s sound. An i d e n t i f y i n g c h a r a c t e r i s t i c of t h e s e t r e a t m e n t s i s t h a t the p a t i e n t i s r e l a t i v e l y p a s s i v e and does not p u r p o s e f u l l y u t i l i z e l e a r n e d c o g n i t i v e or b e h a v i o u r a l 56 t e c h n i q u e s f o r r e l i e f . The t h e r a p e u t i c t a s k l a r g e l y r e q u i r e s c o m p l i a n c e w i t h the p r e s c r i p t i o n of the t h e r a p i s t . By t h i s d e f i n i t i o n , f o r example, d i e t change regimens a r e c l a s s i f i e d as p a s s i v e . A l l tend t o be c h a r a c t e r i z e d by t h e r a p e u t i c e f f o r t d i r e c t e d a t changing the o r g a n i c b a s i s f o r the t i n n i t u s sound i t s e l f . S u b j e c t i v e d i s t r e s s a s s o c i a t e d w i t h t i n n i t u s i s l a r g e l y i g n o r e d . T h i s approach would be d e f i c i e n t i f p s y c h o l o g i c a l p r o c e s s e s were found t o be i m p o r t a n t i n f l u e n c e s of t i n n i t u s d i s t r e s s . The a c t i v e t r e a t m e n t s , i n c o n t r a s t , aim t o impart c o g n i t i v e and b e h a v i o u r a l s k i l l s which the t i n n i t e u r would p u r p o s e f u l l y e x e r c i s e throughout the t h e r a p e u t i c p r o c e s s and use t h e r e a f t e r . These would be used i n d e p e n d e n t l y o f , or i n c o n j u n c t i o n w i t h , m e d i c a t i o n , a p p a r a t u s , or s u r g e r y . The aim of the a c t i v e t r e a t m e n t s i s not n e c e s s a r i l y the e l i m i n a t i o n of the t i n n i t u s symptom, but r a t h e r t o r e l i e v e d i s t r e s s f e l t by the t i n n i t e u r . One of the most w i d e l y used and s t u d i e d of the p a s s i v e t r e a t m e n t s i s masking. The premise has been t h a t an e x t e r n a l sound, e i t h e r n a t u r a l l y - o c c u r r i n g or s y n t h e s i s e d , can be superimposed on the t i n n i t u s sound t o b r i n g r e l i e f . O r i g i n a l l y Jones and Knudsen (1928) suggested t h a t the p r e s e n t a t i o n of masking sounds might p r o v i d e t i n n i t e u r s w i t h some r e l i e f . Indeed many t i n n i t e u r s have ex p e r i m e n t e d autonomously w i t h e n v i r o n m e n t a l sounds, e.g. n o i s e and music, i n at t e m p t s t o c o v e r the t i n n i t u s i n some way. I t has been found t h a t t i n n i t u s sounds have d i f f e r e n t 57 masking c h a r a c t e r i s t i c s than e x t e r n a l l y p r e s e n t e d sounds (Penner, B r a u t h , & Hood, 1981). When one group of s u b j e c t s was i n s t r u c t e d t o a d j u s t the i n t e n s i t y of a masking sound so t h a t i t j u s t masked t h e i r t i n n i t u s , they t y p i c a l l y r e q u i r e d a r a p i d i n c r e a s e i n i n t e n s i t y d u r i n g the f i r s t 10 or 15 minutes f o l l o w e d by a l e v e l l i n g o f f of the r e q u i r e d i n t e n s i t y . In c o n t r a s t , when s u b j e c t s were r e q u i r e d t o mask a s y n t h e s i z e d tone superimposed on the t i n n i t u s of 10 dB s e n s a t i o n l e v e l (SL) above the s u b j e c t ' s own a b s o l u t e t h r e s h o l d a t a g i v e n f r e q u e n c y , 90% r e q u i r e d e s s e n t i a l l y the same i n t e n s i t y over time t o mask the ton e . The a u t h o r s p o s t u l a t e d t h a t t h i s d i f f e r e n t i a l e f f e c t between t i n n i t u s and e x t e r n a l t ones was because each might not a f f e c t p r i m a r y nerve f i b r e s i n the same way or p o s s i b l y because the t i n n i t u s o r i g i n a t e d a t a h i g h e r l e v e l c e n t r a l s i t e r a t h e r than i n the p e r i p h e r a l a u d i t o r y system. The a d v e n t i t i o u s use of n a t u r a l l y o c c u r r i n g background sounds was s y s t e m a t i c a l l y d e v e l o p e d i n t o a t r e a t m e n t mode i n the mid-1970's by a r e s e a r c h group a t the U n i v e r s i t y of Oregon M e d i c a l S c h o o l . T h e i r i n v e n t i o n , the masker, i s a m i n i a t u r i s e d d e v i c e which i s worn be h i n d the ear and which b r o a d c a s t s a masking sound i n t o the ear (Vernon, 1977; Vernon and S c h l e u n i n g , 1978). In a d d i t i o n t o the s e s y n t h e t i c a l l y produced masking sounds, t h e r e i s a t l e a s t one case study r e p o r t e d of a t i n n i t e u r w i t h d e b i l i t a t i n g t i n n i t u s who used a t r a n s i s t o r r a d i o w i t h a m i n i a t u r e e a r - s p e a k e r t o produce masking music. T h i s brought c o n s i d e r a b l e r e l i e f ( C a s s e l , 1978). 58 In c e r t a i n c a s e s , a m p l i f i c a t i o n of ambient sound by wearing a h e a r i n g a i d can b r i n g r e l i e f from t i n n i t u s (Vernon and M e i k l e , 1981). A v a r i a n t of the masker, c a l l e d a t i n n i t u s i n s t r u m e n t , combines a masker and h e a r i n g a i d i n one a p p a r a t u s (Vernon and M e i k l e , 1981). I t might be t h a t the h i g h e r l e v e l of ambient n o i s e h e a r d by the wearer would a s s i s t the masking p r o c e s s . In the H a l l a m , Rachman, and H i n c h c l i f f e (1984) study i t was noteworthy t h a t the members of the two e m p i r i c a l c l u s t e r s w i t h the l e a s t h e a r i n g l o s s r e p o r t e d most masking e f f e c t from e n v i r o n m e n t a l sounds. In c o n t r a s t , the two c l u s t e r s w i t h h i g h e s t p r o p o r t i o n of severe h e a r i n g l o s s i n t h e i r members had the l a r g e s t r a t i o of members r e p o r t i n g the absence of e n v i r o n m e n t a l masking e f f e c t s . T h i s suggested t h a t improvement i n the h e a r i n g of e n v i r o n m e n t a l sounds might w e l l be a s s o c i a t e d w i t h i n c r e a s e s i n t h e i r masking e f f e c t . The sounds produced by the masking d e v i c e a r e e i t h e r pure tones or n o i s e . I t i s not c l e a r how c l o s e l y the sounds e m i t t e d must match the p i t c h of the t i n n i t u s sound i n o r d e r t o g a i n maximum e f f e c t (McFadden, 1982). Formby and G j e r d i n g e n (1980) found i n a case study t h a t the more the masking sound f r e q u e n c y d e p a r t e d from the t i n n i t u s p i t c h , the g r e a t e r the i n t e n s i t y of masking r e q u i r e d t o mask the t i n n i t u s sound. Masking sounds do not mask the t i n n i t u s sounds i n ev e r y c a s e . Feldmann (1971) r e p o r t e d t h a t masking was u n s u c c e s s f u l i n 11% of s e v e r e l y a f f e c t e d c a s e s . However, he r e p o r t e d t h a t any sound (and not o n l y a c a r e f u l l y matched sound) had s u c c e s s f u l l y masked t i n n i t u s i n 23% of the sample. Moreover he found t h a t a masking sound 59 p r e s e n t e d c o n t r a l a t e r a l l y t o the u n a f f e c t e d ear i n u n i l a t e r a l t i n n i t u s s u c c e s s f u l l y masked the t i n n i t u s i n c e r t a i n c a s e s . T h i s s u g g e s t s t h a t the e f f e c t s of masking a r e c e n t r a l r a t h e r than i n the p e r i p h e r a l a u d i t o r y a p p a r a t u s ; a p o s i t i o n c o n s i s t e n t w i t h e f f o r t s t o i n t e r v e n e by p s y c h o l o g i c a l means. When tones w i t h f r e q u e n c i e s o t h e r than the f r e q u e n c i e s of o t o a c o u s t i c e m i s s i o n s (OAE) were b r o a d c a s t t o e a r s w i t h OAEs, the OAEs were o f t e n found t o be suppressed (Kemp and Chum, 1980; W i l s o n and S u t t o n , 1981; Zurek, 1981). OAEs p r e s e n t e d a more o b j e c t i v e way of i n v e s t i g a t i n g the impact of masking sound but g e n e r a l i z a t i o n t o t i n n i t u s has not been c l e a r l y e s t a b l i s h e d . E v a l u a t i v e s t u d i e s of the degree of s u c c e s s these masking d e v i c e s a c h i e v e have i n d i c a t e d t h a t t h e r e has been c o n s i d e r a b l e non-compliance w i t h p r o f e s s i o n a l a d v i c e r e g a r d i n g t h e i r use. V a r i o u s s t u d i e s showed t h a t between 46% and 79% of the recommendees purchased maskers and a t one y e a r f o l l o w - u p o n l y between 30% and 71% were s t i l l u s i n g them (Vernon and M e i k l e , 1981, Sweetow, 1985). These a u t h o r s i n d i c a t e d t h a t t r i a l f i t t i n g of the u n i t s w i t h n o n - o c c l u d i n g ear-moulds and c a r e f u l c o u n s e l l i n g about t h e i r purchase and use might i n c r e a s e a c c e p t a b i l i t y and u t i l i z a t i o n . In g e n e r a l , these e v a l u a t i v e s t u d i e s have been l o o s e l y s t r u c t u r e d s u r v e y s ; they r e l i e d e x c l u s i v e l y on s e l f - r e p o r t d a t a w i t h l i t t l e or no o b j e c t i v e measurement of t r e a t m e n t e f f e c t s and had no c o n t r o l groups. T h e r e f o r e , the r e s u l t s s h o u l d be r e g a r d e d as p r e l i m i n a r y t o f u l l y c o n t r o l l e d e x p e r i m e n t a l i n v e s t i g a t i o n s . R e c e n t l y H a z e l l 60 e t a l . (1985) found t h a t t i n n i t e u r s who were f i t t e d w i t h maskers g a i n e d more r e l i e f than those w e a r i n g t i n n i t u s i n s t r u m e n t s ( c o m b i n a t i o n m a s k e r s / h e a r i n g a i d s ) . T h i s may have r e f l e c t e d the f a c t t h a t c o m b i n a t i o n i n s t r u m e n t u s e r s were prone t o t u r n o f f the masking sound and t o use the i n s t r u m e n t p r i m a r i l y as a h e a r i n g a i d . O v e r a l l H a z e l l e t a l . (1985) found t h a t maskers and c o m b i n a t i o n i n s t r u m e n t s were h e l p f u l t o many t i n n i t e u r s . They were not a b l e t o s p e c i f y which s u b j e c t a t t r i b u t e s p r e d i c t e d s u c c e s s f u l l y whether masking would be s u c c e s s f u l . H a z e l l , et a l . (1985) summarized the d e f i c i e n c i e s i n e x t a n t masker r e s e a r c h and emphasized the importance of u s i n g p l a c e b o c o n t r o l groups. They c i t e d E r l a n d s s o n (1983) who found t h a t e i g h t out of 17 s u b j e c t s b e n e f i t t e d from masking d e v i c e s , but t h a t s i x of a c o n t r o l group of 17 who were f i t t e d w i t h p l a c e b o maskers, r e p o r t e d s i g n i f i c a n t improvement. An e v a l u a t i o n of the e f f i c a c y of maskers and t i n n i t u s i n s t r u m e n t s would depend on how c i r c u m s c r i b e d a d e f i n i t i o n was used i n d e f i n i n g the group t o which masking was a p p l i e d . The most c o n s e r v a t i v e e s t i m a t e of c o m p l i a n c e r a t e s c o u l d be based on a denominator which i n c l u d e d a l l t i n n i t e u r s seen a t a c l i n i c . A p p a r e n t l y h i g h e r s u c c e s s r a t e s c o u l d be o b t a i n e d by e x c l u d i n g the f o l l o w i n g c a t e g o r i e s of c l i e n t s : those who were p r e j u d g e d by a c l i n i c i a n not t o be s u i t a b l e f o r masking; those who, a l t h o u g h recommended f o r maskers, d i d not a c q u i r e the d e v i c e a f t e r a s h o r t p e r i o d of t r i a l use; and u s e r s who, a l t h o u g h owning 61 maskers, stopped u s i n g them b e f o r e the f i n a l measurement of e f f i c a c y was made. There a r e a l s o q u e s t i o n s about the g e n e r a l i z a b i l i t y of the s t u d i e s t h a t a r e a v a i l a b l e . S u b j e c t s i n the Oregon masking t r e a t m e n t t r i a l s were u n l i k e l y t o be r e p r e s e n t a t i v e of t i n n i t e u r s i n g e n e r a l but r a t h e r c o u l d be a s e l e c t s ubset of the p o p u l a t i o n which was m o t i v a t e d t o a t t e n d the c l i n i c , had s e vere d i s t r e s s , and who c o u l d a f f o r d the f e e s . Another reason f o r c a u t i o n i n e v a l u a t i n g the masking d a t a i n t h i s study would be t h a t i t was based on r e p o r t s from one p r e s t i g i o u s c l i n i c , the Kresge c l i n i c i n P o r t l a n d , which might have evoked s i t u a t i o n -s p e c i f i c e f f e c t s from i t s c l i e n t s . To summarize: the outcome d a t a on the use of maskers have y i e l d e d r e s u l t s which show some l i m i t e d s u c c e s s i n r e l i e v i n g d i s t r e s s from t i n n i t u s . The s t u d i e s , however, have problems w i t h e x p e r i m e n t a l d e s i g n , d e f i n i t i o n a l i s s u e s , and g e n e r a l i z a t i o n from the p a r t i c u l a r s e t t i n g and s u b j e c t s . Masking remains one of the most i n t e n s i v e l y i n v e s t i g a t e d t r e a t m e n t s f o r t i n n i t u s and r e s e a r c h i n t o masking i s p r o c e d i n g . McFadden (1982) c a u t i o n e d t h a t many maskers and t i n n i t u s i n s t r u m e n t s (which t y p i c a l l y have maximum o u t p u t s between 85 and 110 bBA) c o u l d exceed the most w i d e l y used s a f e t y g u i d e l i n e f o r exposure t o sound: a maximum of 90 bBA f o r no more than 8 hours a day and f o r no more than 5 days a week. Voroba (1979b) p o i n t e d out t h a t , whereas e x c e s s i v e exposure t o e n v i r o n m e n t a l n o i s e had been l i n k e d c a u s a l l y t o ear p a t h o l o g y , too l i t t l e 62 c a u t i o n had been e x e r c i s e d i n p r e s c r i b i n g t i n n i t u s maskers which b r o a d c a s t e d a sound f o r l o n g p e r i o d s . He su g g e s t e d t h a t t h e r e were p o t e n t i a l r i s k s t o h e a r i n g and p o s s i b l y t o o v e r a l l h e a l t h from such exposure and t h a t t h i s needed t o be examined (Voroba, 1979a). However, H a z e l l e t a l . (1985) found t h a t t h e r e were no s i g n i f i c a n t d e l e t e r i o u s e f f e c t s on h e a r i n g caused by wearing of maskers or c o m b i n a t i o n i n s t r u m e n t s f o r a p e r i o d of about s i x months. A l t h o u g h the l o n g - t e r m use of maskers might have u n d e s i r a b l e s i d e - e f f e c t s , i t does not f o l l o w t h a t they s h o u l d not be used. What i s i m p o r t a n t i s t h a t t h e r e s h o u l d be a net g a i n t o the user when comparing r i s k s t o b e n e f i t s . I t has been obse r v e d t h a t , f o l l o w i n g a p e r i o d of masker use, some t i n n i t e u r s r e p o r t e d t h a t t h e r e were ti m e s when the t i n n i t u s sound was absent f o r s e v e r a l seconds b e f o r e r e a p p e a r i n g . T h i s s i l e n c i n g e f f e c t has been termed " r e s i d u a l i n h i b i t i o n . " Feldmann (1971) r e p o r t e d a s i n g l e - c a s e study i n which a h a l f - s e c o n d b u r s t of masking sound i n h i b i t e d the t i n n i t u s sound f o r p e r i o d s of between o n e - h a l f and one and one-h a l f seconds a p p r o x i m a t e l y . Sound p r e s e n t e d t o the c o n t r a l a t e r a l ear i n c r e a s e d i n h i b i t i o n t i m e s by 59% compared t o i p s i l a t e r a l p r e s e n t a t i o n . The p e r i o d of i n h i b i t i o n i n c r e a s e d w i t h i n c r e a s i n g sound i n t e n s i t y but t h i s p e r i o d was not a s s o c i a t e d w i t h the fr e q u e n c y of the sound p r e s e n t e d . The f a c t t h a t r e s i d u a l i n h i b i t i o n o c c u r r e d f o r v a r y i n g l e n g t h s of t i m e , and t h a t i n some p a t i e n t s t h e r e was a seemingly permanent absence of t i n n i t u s a f t e r exposure have l e d c e r t a i n 63 r e s e a r c h e r s t o b e l i e v e t h a t t h i s phenomenon might have promise as a t r e a t m e n t f o r a t l e a s t some ca s e s (Vernon, Johnson, S c h l e u n i n g , and M i t c h e l l , 1980). Feldman (1971) suggested t h a t , i f an u n d e r l y i n g n e u r a l mechanism which might be b l o c k i n g the t i n n i t u s a c t i v i t y , " c o u l d be t r a i n e d or a c t i v a t e d , t h e r e might be a way t o c u r e p a t i e n t s of t h e i r d i s t r e s s i n g t i n n i t u s " (p. 143) . T h i s o p t i m i s m has been tempered by McFadden (1982) who p o i n t e d out the many unknowns i n u s i n g r e s i d u a l i n h i b i t i o n as a t r e a t m e n t . There i s the f i n d i n g t h a t about o n e - t h i r d of p a t i e n t s g i v e n r e s i d u a l i n h i b i t i o n t r e a t m e n t e x p e r i e n c e d i n c r e a s e d t i n n i t u s (Vernon and M e i k l e , 1981). These a u t h o r s saw a p o s s i b l e p a r a l l e l between the r e s i d u a l i n h i b i t i o n , which i n some c a s e s f o l l o w s the use of maskers, and the temporary r e l i e f from p a i n a f t e r e l e c t r i c a l s t i m u l a t i o n of c e r t a i n nerve s i t e s by a p r o c e s s termed t r a n s c u t a n e o u s e l e c t r i c a l nerve s t i m u l a t i o n (TENS), ( e . g . Wolf and Rao, 1983). Numerous c l a s s e s of drugs have been used i n a t t e m p t s t o a l l a y t i n n i t u s . They range from v i t a m i n s , l o c a l a n e s t h e t i c s and a n t i c o n v u l s a n t s t o b a r b i t u a t e s and v a s o d i l a t o r s . The r e s e a r c h f i n d i n g s on t h e i r e f f e c t i v e n e s s were reviewed by McFadden (1982). In summary the s e were: 1. W h i l e c e r t a i n drugs have produced temporary and o c c a s i o n a l l o n g - t e r m d e c r e a s e s , or even e l i m i n a t i o n of t i n n i t u s , t h e i r e f f e c t i v e n e s s i s u n p r e d i c t a b l e . 2. The s i d e - e f f e c t s of some of the more e f f e c t i v e drugs 64 a r e s u f f i c i e n t l y a v e r s i v e t o p r e c l u d e t h e i r g e n e r a l use. 3. Drug t h e r a p y f o r t i n n i t u s has not d e v e l o p e d y e t t o the sta g e where an e f f e c t i v e and s a f e m e d i c a t i o n w i t h wide u s e f u l n e s s was a v a i l a b l e . S u r g i c a l t r e a t m e n t s f o r t i n n i t u s have been reviewed by House and Brackmann (1981) and McFadden (1982). A f t e r s u r g e r y f o r an a c o u s t i c neuroma, 40% of p a t i e n t s r e p o r t e d improvement i n the t i n n i t u s and 50% a wo r s e n i n g . A f t e r stapendectomy, 74% were improved, and a f t e r l a b y r i n t h i n e s e c t i o n of the e i g h t h n e r v e , about 45% were improved. S u r g i c a l t r e a t m e n t , w h i l e s u c c e s s f u l i n some c a s e s , can be u n r e l i a b l e . In a d d i t i o n , s t u d i e s do not i n d i c a t e outcomes i n the l o n g e r term. Apart from these c a u t i o n s i t s h o u l d be borne i n mind t h a t the e f f e c t s of s u r g e r y a r e f r e q u e n t l y i r r e v e r s i b l e . H a z e l l (1981c) noted t h a t s e c t i o n of the e i g h t h nerve might p r e c l u d e the use of f u t u r e , as y e t u n d i s c o v e r e d , t r e a t m e n t s . House and Brackmann (1981) have noted t h a t 80% of t h e i r p a t i e n t s w i t h c o c h l e a r i m p l a n t s r e p o r t e d improvement i n t h e i r t i n n i t u s . C o c h l e a r i m p l a n t s a r e d e v i c e s which a r e s u r g i c a l l y i m p l a n t e d i n the h e a r i n g mechanism. They have an i n d u c t i o n c o i l by means of which an incoming a c o u s t i c s i g n a l can be c o n v e r t e d t o an e l e c t r i c a l s i g n a l which s t i m u l a t e s the c o c h l e a and i s hear d as a sound. They suggested t h a t e l e c t r i c a l s t i m u l a t i o n of the i n n e r ear and the c e n t r a l pathways might h o l d some promise as a t r e a t m e n t method and t h e y , t o o , drew a comparison between t h i s and TENS. The work on e l e c t r i c a l s t i m u l a t i o n has been 65 reviewed by McFadden (1982) who c o n c l u d e d t h a t i t was a t e c h n i q u e worthy of f u r t h e r i n v e s t i g a t i o n . U n t i l the c o m p l e t i o n of more e x t e n s i v e r e s e a r c h and the r u n n i n g of c l i n i c a l t r i a l s , TENS c o u l d not be c o n s i d e r e d t o be a p r i m a r y t h e r a p e u t i c t e c h n i q u e f o r t i n n i t u s a t p r e s e n t . In more r e c e n t work, Vernon & Fenwick (1985) t e s t e d 50 t i n n i t e u r s by a p p l y i n g v a r i o u s e l e c t r i c a l waveforms t r a n s d e r m a l l y by e l e c t o d e s p l a c e d i p s i l a t e r a l l y t o the ear w i t h more se v e r e t i n n i t u s on the p r e a u r i c u l a r and p o s t a u r i c u l a r r e g i o n s . In a second s t u d y , e l e c t r o d e s were p l a c e d on the two m a s t o i d s . The d e s i g n p r o v i d e d f o r each s u b j e c t t o r e c e i v e a p l a c e b o t r e a t m e n t f o l l o w e d by the e l e c t r i c a l s t i m u l a t i o n . Only one s u b j e c t r e p o r t e d a r e d u c t i o n i n t i n n i t u s i n t e n s i t y i n the p l a c e b o phase, and p o s t - t r e a t m e n t 28% reached the e x p e r i m e n t e r s ' c r i t e r i o n of a r e d u c t i o n of 40% or more. The d i m i n u t i o n t y p i c a l l y l a s t e d f o r o n l y about t h r e e h o u r s . No n e g a t i v e e f f e c t s were r e p o r t e d . These r e s e a r c h e r s c o n c l u d e d t h a t the s u p p r e s s i v e e f f e c t s of n o n - i n v a s i v e p r o c e d u r e s such as they t r i e d were exceeded by more i n v a s i v e p r o c e d u r e s such as used by Aran & C a z a l s (1981) and by Portman et a l . (1979) who both used e l e c t r i c a l s t i m u l a t i o n t o the round window membrane. They f e l t t h a t deeper e l e c t r o d e placements h e l d g r e a t e r promise f o r f u t u r e r e s e a r c h . However, from the t r e a t m e n t p e r s p e c t i v e , the i n v a s i v e n e s s of deeper placement i s p r o b a b l y a s s o c i a t e d w i t h i n c r e a s e d r i s k s t o the p a t i e n t . E n g e l b e r g & Bauer (1985) r e p o r t e d a 81% s u c c e s s r a t e i n 66 " i m p r o v i n g the t i n n i t u s " i n 20 s u b j e c t s (33 e a r s ) by TENS. Improvement was somewhat a r b i t r a r i l y d e f i n e d as e i t h e r a complete r e m i s s i o n i n t i n n i t u s or a decrease i n i t s f r e q u e n c y . They used a s i n g l e b l i n d p r o c e d u r e i n c l u d i n g a c o n t r o l group (who responded m i n i m a l l y t o the c o n t r o l p r o c e d u r e ) . U n f o r t u n a t e l y t i n n i t u s i n t e n s i t y was n e i t h e r o b j e c t i v e l y nor s u b j e c t i v e l y measured. D u r a t i o n of improvement ranged from 20 minutes t o more than s i x months. In a d d i t i o n t o the above t r e a t m e n t s , t h e r e have been numerous c l a i m s f o r the s u c c e s s of o t h e r t e c h n i q u e s e.g. h y p n o s i s (Marlowe, 1973); and a c u p u n c t u r e (Mann, 1974). Hansen, Hansen, & Bentzen (1982) found some b e n e f i t s t o t i n n i t e u r s from a c u p u n c t u r e t r e a t m e n t . In a s t u d y of hypnotherapy t r e a t m e n t f o r t i n n i t u s (Marks, K a r l , & O n i s i p h o r o u , 1985), 36% of 14 s u b j e c t s had improved t o l e r a n c e f o r t h e i r t i n n i t u s a l t h o u g h the l o u d n e s s and q u a l i t y were unchanged. N e i t h e r of t h e s e t r e a t m e n t s has been s u b j e c t e d t o a n y t h i n g a p p r o a c h i n g f u l l e x p e r i m e n t a l t e s t i n g . T h e r e f o r e they s h o u l d be r e g a r d e d as s p e c u l a t i v e . S i n c e t r e a t m e n t of t i n n i t u s by m e d i c a t i o n , s u r g e r y , and o t h e r means has not been found t o b r i n g r e l i e f r e l i a b l y , i t seemed i m p o r t a n t t o i n v e s t i g a t e p s y c h o l o g i c a l t e c h n i q u e s . However, f o r m a l l y deduced and c l i n i c a l l y t e s t e d p s y c h o l o g i c a l i n t e r v e n t i o n s a r e almost t o t a l l y absent from the l i t e r a t u r e . One of the e a r l i e s t s u g g e s t i o n s i n the l i t e r a t u r e f o r an a c t i v e t r e a t m e n t approach was made by Fowler (1943) who wrote of t i n n i t u s sounds: "They seem u n n a t u r a l , and t h e y a r e u n n a t u r a l 67 because they are an i l l u s i o n and, l i k e a l l i l l u s i o n s , t e n d t o be e x a g g e r a t e d " (p. 392). T i n n i t u s sounds which were not pure tones would be more l i k e l y t o be e x a g g e r a t e d i n terms of l o u d n e s s , t i m b r e , and d i s t r e s s , Fowler n o t e d . T h i s l e d him t o suggest t h a t a t i n n i t e u r who was d i s t r e s s e d by t h e s e sounds might be t r e a t e d by a r a t i o n a l l y - b a s e d t h e r a p y i n which the f a c t s of t h i s " p s y c h i c m a g n i f i c a t i o n was f i r m l y p l a n t e d i n h i s c o n s c i o u s n e s s u n t i l he u n d e r s t a n d s t h a t [ t h e s e f a c t s ] do not c o r r e s p o n d t o h i s s t a t e m e n t s as t o the s e v e r i t y of the symptom" ( F o w l e r , 1943, p. 397). Fowler (1942, 1943) noted i n h i s e a r l y r e s e a r c h the tenuous r e l a t i o n s h i p between the l o u d n e s s of the t i n n i t u s sound and the degree of d i s t r e s s . T h i s was a l s o noted by Reed (1960) who r e p o r t e d t h a t s e l f - r e p o r t measures of l o u d n e s s of t i n n i t u s were not c l o s e l y r e l a t e d t o more o b j e c t i v e measures of l o u d n e s s ; nor do the l a t t e r c o r r e s p o n d t o s e l f - r e p o r t e d s e v e r i t y of d i s t r e s s . In e m p h a s i z i n g a t r e a t m e n t approach which has elements of r a t i o n a l - e m o t i v e t h e r a p y ( E l l i s , 1962), he suggested p l a y i n g a tone t o the t i n n i t e u r a t the same low i n t e n s i t y of the i n d i v i d u a l ' s own t i n n i t u s sound t o c o n v i n c e the t i n n i t e u r t h a t t h i s weak sound o b v i o u s l y d i d "not c o r r e s p o n d t o the s e v e r i t y of the problem....The p a t i e n t must be educated t o r a t i o n a l i z e h i s symptoms and a c c e p t them a t t h e i r f a c e v a l u e and not a l l o w them t o "get on h i s n e r v e s " ( F o w l e r , 1943, p. 397). A f t e r m e d i c a l i n v e s t i g a t i o n the t i n n i t e u r i s o f t e n g i v e n v e r b a l r e a s s u r a n c e s t h a t t i n n i t u s i s a common symptom; t h a t i t 68 i s not a s e r i o u s , l i f e - t h r e a t e n i n g d i s e a s e ; t h a t i t does not l e a d i n e v i t a b l y t o t o t a l d e a f n e s s ; nor does i t imply the p r e s e n c e or p r o s p e c t of mental d i s o r d e r ( t h e s e a l l b e i n g t y p i c a l f e a r s of new t i n n i t e u r s ) . He or she i s then t y p i c a l l y c o u n s e l l e d t o l e a r n t o l i v e w i t h the t i n n i t u s because t h e r e i s no s u c c e s s f u l t r e a t m e n t i n most c a s e s . H e l l e r and Bergman (1953) r e p o r t e d t h a t 94% of t h e i r sample of n o r m a l - h e a r i n g s u b j e c t s became aware of t i n n i t u s - l i k e sounds when they were p l a c e d i n a sound-reduced environment. As an i n f o r m a t i o n a l component of t h e r a p y , t h i s knowledge might s e r v e a n o r m a l i z i n g f u n c t i o n t o t i n n i t e u r s . The e f f e c t s of s u p p l y i n g t h i s i n f o r m a t i o n and o t h e r r e a s s u r i n g f a c t s , have not been f o r m a l l y e v a l u a t e d . As T y l e r and Baker ( u n p u b l i s h e d m a n u s c r i p t ) have p o i n t e d o u t , " i t i s not enough t o say ' Y o u ' l l j u s t have t o l e a r n t o l i v e w i t h i t . ' T i n n i t u s s u f f e r e r s need t o be shown how t o l i v e w i t h i t , " (p. 12). I t i s i n t h i s sphere t h a t p s y c h o l o g y has an i m p o r t a n t c o n t r i b u t i o n t o make t o t r e a t m e n t . In what has come t o be known as the c o g n i t i v e - b e h a v i o u r a l t r e a t m e n t s f o r c o p i n g w i t h c h r o n i c p h y s i c a l d i s t r e s s , the p a t i e n t p l a y s an a c t i v e r o l e (as d e f i n e d a b o v e ) . "A common f e a t u r e of c o g n i t i v e - b e h a v i o u r a l t r e a t m e n t s i s t h a t the p a t i e n t i s viewed as an i m p o r t a n t agent i n g u i d i n g , d i r e c t i n g , and c o n t r o l l i n g h i s or her own h e a l t h , d i s e a s e , and i l l n e s s " (Turk, Meichenbaum, and, Genest, 1983, p. 33). These t e c h n i q u e s have been used w i t h some s u c c e s s i n treatment of c h r o n i c headache (e.g . B a k a l , Demjen, and Kaganov, 1981; Demjen and B a k a l , 1979; 69 H o l r o y d , A n d r a s i k , and Westbrook, 1977), m i g r a i n e (e.g. M i t c h e l l and White, 1977), and m y o f a s c i a l p a i n d y s f u n c t i o n (e.g. Stenn, M o t h e r s i l l and Brooke, 1979). The r e p o r t of t h r e e c a s e -s t u d i e s by MacLeod-Morgan, C o u r t , and R o b e r t s (1983) i s one of few examples of t h i s t e c h n i q u e i n the t i n n i t u s l i t e r a t u r e . They used an i n t e r v e n t i o n i n which h y p n o t i c i n d u c t i o n t o g e t h e r w i t h r e l a x a t i o n t r a i n i n g and c o g n i t i v e r e s t r u c t u r i n g were s u c c e s s f u l i n r e d u c i n g d i s t r e s s caused by t i n n i t u s sounds. In the c o g n i t i v e component t i n n i t e u r s were t r a i n e d t o r e i n t e r p r e t the t i n n i t u s sounds t o be something more a c c e p t a b l e . Examples of t r a n s f o r m a t i o n s used i n c l u d e d s p l a s h i n g f o u n t a i n s and the hum of a c a r e n g i n e . The a u t h o r s f e l t t h a t the t e c h n i q u e h e l d promise but i t was not c l e a r which of the p a r t i c u l a r components of the t r e a t m e n t package were e f f e c t i v e i n r e d u c i n g d i s t r e s s . No q u a n t i t a t i v e d a t a were s u p p l i e d i n t h i s r e p o r t and, b e i n g a c a s e - s t u d y , no c o n t r o l s were used. C o n c l u s i o n s r e g a r d i n g the e f f e c t i v e n e s s of the t e c h n i q u e s used s h o u l d t h e r e f o r e be guarded. Sweetow's (1985) paper d e s c r i b e d group c o g n i t i v e -b e h a v i o u r a l t h e r a p y f o r t i n n i t u s d i s t r e s s i n some d e t a i l and c l a i m s s u c c e s s i n t r e a t m e n t but p r e s e n t e d no d a t a . N e v e r t h e l e s s i t i s l i k e l y t o be an i n f l u e n t i a l r e p o r t because of the c l e a r and c o n f i d e n t t r a n s l a t i o n of c o g n i t i v e - b e h a v i o u r a l t e c h n i q u e s from p a i n t o t i n n i t u s , and the d i s s e m i n a t i o n of t h i s t o p r o f e s s i o n a l s d e a l i n g w i t h t i n n i t e u r s . One h e a r i n g - i m p a i r e d c h i l d i n Graham's (1981b) study s a i d t h a t he l i k e d h i s t i n n i t u s , found i t s o o t h i n g , and h e l p e d him t o get t o s l e e p . W h i l e t h i s i s a n e c d o t a l , i t i s an example of how a p o s i t i v e i n t e r p r e t a t i o n 70 can be made of a sound commonly h e l d t o be u n d e n i a b l y a v e r s i v e . House and Brackmann (1981) p o s t u l a t e d t h a t i n c r e a s i n g muscle t e n s i o n causes g r e a t e r d i s t r e s s from t i n n i t u s and a l s o i n c r e a s e s the l o u d n e s s of the t i n n i t u s . They proposed t h a t t r a i n i n g t i n n i t e u r s t o r e l a x ( p a r t i c u l a r l y t h r o u g h b i o f e e d b a c k ) , might o f f e r them a way t o c o n t r o l t h e i r t i n n i t u s . As McFadden (1982) p o i n t e d o u t , the t r e a t m e n t of t i n n i t u s by b i o f e e d b a c k depended on the assumption (not y e t f o r m a l l y e v a l u a t e d ) t h a t t i n n i t u s magnitude i s r e l a t e d t o a n x i e t y . However, i n a c a r e f u l l y d e s i g n e d study i n c o r p o r a t i n g a w a i t i n g - l i s t c o n t r o l group, I r e l a n d & W i l s o n (1985) found t h a t seven s e s s i o n s of r e l a x a t i o n t r a i n i n g had no s i g n i f i c a n t e f f e c t s on the o c c u r r e n c e , awareness, or r a t e d l o u d n e s s of t i n n i t u s , or i n t e r f e r e n c e from i t . A case study r e p o r t e d good r e s u l t s from a comprehensive b e h a v i o u r a l programme i n c l u d i n g t h e r m a l b i o f e e d b a c k t h e r a p y , t i n n i t u s management t r a i n i n g , a s s e r t i v e n e s s t r a i n i n g , c o g n i t i v e t r e a t m e n t of d e p r e s s i o n , and m a r i t a l t h e r a p y (Duckro, P o l l a r d , B r a y , & S c h e i t e r , 1984). T i n n i t u s d i s t r e s s , d e p r e s s i o n , and o t h e r r a t i n g s improved s u b s t a n t i a l l y and the improvement was m a i n t a i n e d a t t h r e e month f o l l o w up. B i o f e e d b a c k t r a i n i n g was g i v e n t o 41 t i n n i t e u r s who had u n s u c c e s s f u l l y attempted a v a r i e t y of o t h e r t r e a t m e n t s (House, M i l l e r , and House, 1977). A c o m b i n a t i o n of f r o n t a l i s e l e c t o m y o g r a p h i c (EMG) and d i g i t a l t e mperature b i o f e e d b a c k was used. I t was found t h a t 80% of p a t i e n t s r e p o r t e d some 71 improvement i n t h e i r t i n n i t u s a t p o s t - t r e a t m e n t . U n f o r t u n a t e l y t h i s c o n c l u s i o n was based on s e l f - r e p o r t d ata o n l y ; t h e r e was no c o n t r o l group; and t h e r e was no s t a t i s t i c a l e v a l u a t i o n of the d a t a . House (1978) r e p o r t e d on f o l l o w - u p d a t a a t s i x - t o twelve-month p o s t - t r e a t m e n t and 56% c l a i m e d some improvement. I f the " s l i g h t l y improved" c a t e g o r y were e x c l u d e d , t h e s e r e s u l t s would be s u b s t a n t i a l l y l o w e r : 36% were much improved or v e r y much improved a t p o s t - t r e a t m e n t , and 17% a t f o l l o w - u p . Grossan (1976) used both s e l f - r e p o r t and lo u d n e s s b a l a n c e e s t i m a t e s i n a b i o f e e d b a c k study u s i n g f r o n t a l i s EMG. While 100% of p r e s b y c u s i s s u b j e c t s r e p o r t e d improvement p o s t - t r e a t m e n t i n t he sense t h a t they c o u l d "cope w i t h i t , " no improvement was r e f l e c t e d i n the o b j e c t i v e l y measured t i n n i t u s l o u d n e s s . S e v e n t y - f o u r p e r c e n t of a c o u s t i c trauma s u b j e c t s s e l f - r e p o r t e d improvement, but o n l y 11% improvement was r e f l e c t e d i n o b j e c t i v e d a t a . For a c r a n i a l / c e r v i c a l i n j u r y group, t h e s e f i g u r e s were 81% t o 10% r e s p e c t i v e l y . Both Grossan and House e t a l . noted marked de c r e a s e s i n the use of v a r i o u s m e d i c a t i o n s by t h e i r s u b j e c t s . In a l l these s t u d i e s t h e r e was o n l y g r o s s measurement of improvement; i t was o f t e n not c l e a r whether the improvement r e f e r r e d t o s u b j e c t i v e l o u d n e s s or d i s t r e s s ; and, i m p o r t a n t l y , i n the absence of c o n t r o l g roups, t h e r e c o u l d be no c e r t a i n t y as t o what the e f f e c t i v e components of tr e a t m e n t were. Walsh & G e r l e y (1985) used a combined t h e r m a l b i o f e e d b a c k and r e l a x a t i o n t r a i n i n g t r e a t m e n t and found s t a t i s t i c a l l y 72 s i g n i f i c a n t d e c l i n e s i n t i n n i t u s l o u d n e s s and annoyance. S i x t y -f i v e p e r c e n t of s u b j e c t s r e p o r t e d a s u b j e c t i v e r e d u c t i o n of t i n n i t u s . There was no t r u e c o n t r o l group and e f f e c t s of b i o f e e d b a c k and r e l a x a t i o n t r a i n i n g were not s e p a r a t e d i n t h i s s t u d y . H a l l a m , Rachman, and H i n c h c l i f f e (1984) proposed a h a b i t u a t i o n model f o r e x p l a i n i n g the p r o c e s s by which most t i n n i t e u r s a d j u s t e d t o the symptom. However Rachman ( p e r s o n a l communication, September, 1983) found t h a t s u b j e c t s i n a p i l o t t e s t of t h i s model d i d not r e l i a b l y h a b i t u a t e t o the r e p e a t e d p r e s e n t a t i o n of a tone s i m i l a r t o the t i n n i t u s sound i n p i t c h . The f i n d i n g s of Penner, B r a u t h & Hood (1981) might o f f e r some c l u e s as t o why a t r e a t m e n t p r o t o c o l d i r e c t e d a t h a b i t u a t i n g t i n n i t e u r s t o an e x t e r n a l sound might not work: they s u g g e s t e d t h a t f o r some t i n n i t e u r s the n e u r a l p r o c e s s p r o d u c i n g the t i n n i t u s might be r e l a t i v e l y independent of the p r o c e s s of p e r c e i v i n g e x t e r n a l sounds. Another more d r a s t i c t r e a t m e n t by exposure t o a " t r a u m a t i z i n g t one" of 120 dB f o r t h r e e ten-minute p e r i o d s one week a p a r t , was r e p o r t e d by Reed and C h r i s t i a n (1961). The c o n t r o l group was l e d t o b e l i e v e t h a t the tone was b e i n g p r e s e n t e d even though they c o u l d not hear i t , whereas i n f a c t no tone was b e i n g p r e s e n t e d . E x p e r i m e n t a l group s u b j e c t s who were a c t u a l l y exposed t o the tone e x p e r i e n c e d e i t h e r a l l e v i a t i o n or e x a c e r b a t i o n of the t i n n i t u s a t a s i g n i f i c a n t l y d i f f e r e n t l e v e l compared t o c o n t r o l s , but the e f f e c t s i n e i t h e r d i r e c t i o n were o n l y temporary. I t had been h y p o t h e s i s e d t h a t " p a r t i a l c o c h l e a r f a t i g u e " might be h e l p f u l i n t r e a t i n g t i n n i t u s 73 but t h i s was not borne out by t h e s e f i n d i n g s . A p a r t from a few c l e a r l y d e f i n e d and t r e a t a b l e causes of t i n n i t u s , e.g. cerumen on the eardrum, neuroma of the a u d i t o r y n e r v e , and e x c e s s i v e use of a s p i r i n , the m a j o r i t y of t i n n i t u s c a s e s cannot at p r e s e n t be t r e a t e d by removal of the cause. I t i s t o t h i s l a r g e group of t i n n i t e u r s t h a t p s y c h o l o g i c a l t r e a t m e n t s c o u l d p o t e n t i a l l y p r o v i d e r e l i e f . However, r e s e a r c h i n t o p s y c h o l o g i c a l t e c h n i q u e s f o r t r e a t m e n t i s not y e t w e l l d e v e l o p e d . I t i s l i k e l y t h a t t h e s e w i l l i n c r e a s i n g l y be r e l i e d on i n the absence of methods f o r the e l i m i n a t i o n of the p h y s i c a l symptoms of t i n n i t u s . G. C o n c l u s i o n s Only a s m a l l p e r c e n t a g e of t i n n i t e u r s f e e l s s e v e r e d i s t r e s s , but many f i n d i t a d i s t u r b i n g and i n t r u s i v e problem. A s m a l l p r o p o r t i o n of c a s e s w i t h c i r c u m s c r i b e d e t i o l o g i e s can be c u r e d by m e d i c a l t r e a t m e n t but a t p r e s e n t t h i s i s not p o s s i b l e f o r the m a j o r i t y of c a s e s . As w i t h c h r o n i c p a i n , t h e r e f o r e , r e s e a r c h i n t o p s y c h o l o g i c a l i n t e r v e n t i o n s t o promote r e l i e f from t i n n i t u s i s s t r o n g l y i n d i c a t e d . In t h i s e a r l y stage of knowledge about p s y c h o l o g i c a l f a c t o r s a s s o c i a t e d w i t h d i s t r e s s f e l t from t i n n i t u s , a n e c d o t a l c l i n i c a l i n f o r m a t i o n , the s p a r s e l i t e r a t u r e on t h i s s u b j e c t , and h e u r i s t i c p o s s i b i l i t i e s from the presumably r e l e v a n t p a i n l i t e r a t u r e s h o u l d a l l s e r v e as i m p o r t a n t l e a d s f o r 74 f u r t h e r r e s e a r c h . P o s s i b i l i t i e s f o r p s y c h o l o g i c a l f a c t o r s a s s o c i a t e d w i t h t i n n i t u s which have emerged from t h e s e s o u r c e s a r e : f i r s t l y , a r o u s a l and a f f e c t i v e f a c t o r s such as f a t i g u e and a n x i e t y ; s e c o n d l y , c o g n i t i v e f a c t o r s such as a t t e n t i o n t o and d i s t r a c t i o n from the symptom and p e r c e i v e d degree of c o n t r o l ; and t h i r d l y , i n f o r m a t i o n a l f a c t o r s i n c l u d i n g e d u c a t i o n r e g a r d i n g the c o u r s e of the u n d e r l y i n g d i s e a s e and r e a s s u r a n c e s about i n c o r r e c t assumptions of i t s a s s o c i a t i o n w i t h mental d i s o r d e r . Knowledge about t h e s e f a c t o r s c o u l d then s e r v e as elements t o be i n t e g r a t e d i n t o p s y c h o l o g i c a l t r e a t m e n t s . There i s another way i n which p s y c h o l o g y can c o n t r i b u t e . The o b j e c t i v e measurements of the p h y s i c a l p r o p e r t i e s of t i n n i t u s ( m a i n l y i t s p i t c h and i n t e n s i t y ) , have g e n e r a l l y not been found t o be a s s o c i a t e d w i t h s p e c i f i c e t i o l o g i e s , d i s t r e s s l e v e l , or treatment outcome. I t f o l l o w s t h a t measurement of s u b j e c t i v e a s p e c t s of t i n n i t u s and t h e i r e f f e c t s on p s y c h o l o g i c a l f u n c t i o n i n g such as l e v e l of d i s t r e s s , i n t r u s i v e n e s s , and a f f e c t , c o n s t i t u t e a second a r e a t o which p s y c h o l o g i c a l e x p e r t i s e c o u l d be d i r e c t e d . 75 I I I Hypotheses The p r e c e d i n g l i t e r a t u r e r e v i e w has r e p o r t e d the r e l a t i v e l y c o n s i s t e n t r e s u l t from the p a i n l i t e r a t u r e t h a t when a t t e n t i o n was f o c u s s e d on p a i n , t o l e r a n c e t o p a i n d e c r e a s e d . C o n v e r s e l y i t was found t h a t when a t t e n t i o n was f o c u s s e d away from p a i n by d i s t r a c t i n g t e c h n i q u e s , t o l e r a n c e t o p a i n i n c r e a s e d . The e f f e c t s of t i n n i t u s of s h i f t i n g a t t e n t i o n a l f o c u s w i l l be i n v e s t i g a t e d i n t h i s r e s e a r c h . The f i r s t and second h y p o t h e s i s t h e r e f o r e a r e : 1. I t i s h y p o t h e s i s e d t h a t , w h i l e f o c u s s i n g on t i n n i t u s as an e x p e r i m e n t a l t a s k , s u b j e c t s w i l l r e p o r t an i n c r e a s e both i n the i n t e n s i t y of t i n n i t u s and i n the d i s t r e s s f e l t from t i n n i t u s compared w i t h l e v e l s b e f o r e t h i s f o c u s s i n g was r e q u i r e d . 2. I t i s h y p o t h e s i s e d t h a t , w h i l e f o c u s s i n g on a d i s t r a c t i n g t a s k , s u b j e c t s w i l l r e p o r t a d e c r e a s e both i n the i n t e n s i t y of t i n n i t u s and i n the d i s t r e s s f e l t from t i n n i t u s compared w i t h l e v e l s b e f o r e t h i s d i s t r a c t i n g f o c u s s i n g was r e q u i r e d . An i n f o r m a l s u r vey of members of the Vancouver T i n n i t u s S e l f - H e l p Group and a n a l y s i s of i n f o r m a t i o n from f i l e s of t i n n i t e u r s a t the Vancouver G e n e r a l H o s p i t a l T i n n i t u s C l i n i c , b o t h i n d i c a t e d t h a t a n x i e t y was r a t e d as an impo r t a n t f a c t o r i n e x a c e r b a t i n g e x i s t i n g t i n n i t u s . There i s some e v i d e n c e from the 76 p a i n l i t e r a t u r e t h a t a n x i e t y has a s i m i l a r e f f e c t on p a i n . 3. I t i s h y p o t h e s i z e d t h a t , w h i l e p a r t i c i p a t i n g i n an a n x i e t y - p r o v o k i n g t a s k , s u b j e c t s w i l l r e p o r t an i n c r e a s e both i n the i n t e n s i t y of t i n n i t u s and i n the d i s t r e s s f e l t from t i n n i t u s compared w i t h l e v e l s b e f o r e a n x i e t y was in d u c e d . 4. I t i s h y p o t h e s i z e d t h a t when s u b j e c t s r a t e the i n t e n s i t y of t i n n i t u s and the d i s t r e s s f e l t from t i n n i t u s i n a n a t u r a l i s t i c s e t t i n g , t h e s e l e v e l s w i l l be e l e v a t e d when s u b j e c t s r a t e themselves as r e l a t i v e l y more a n x i o u s . An i n f o r m a l s u r vey of members of the Vancouver T i n n i t u s S e l f - H e l p Group and a n a l y s i s of i n f o r m a t i o n from f i l e s of t i n n i t e u r s a t the Vancouver G e n e r a l H o s p i t a l T i n n i t u s C l i n i c , b oth i n d i c a t e d t h a t f a t i g u e was r a t e d as an impo r t a n t f a c t o r i n e x a c e r b a t i n g t i n n i t u s . 5. I t i s h y p o t h e s i s e d t h a t , a f t e r p a r t i c i p a t i n g i n a f a t i g u i n g t a s k , s u b j e c t s w i l l r e p o r t an i n c r e a s e b oth i n the i n t e n s i t y of t i n n i t u s and i n the d i s t r e s s f e l t from t i n n i t u s compared w i t h l e v e l s b e f o r e f a t i g u e was ind u c e d . 6. I t i s h y p o t h e s i s e d t h a t when s u b j e c t s r a t e the 77 i n t e n s i t y of t i n n i t u s and the d i s t r e s s f e l t from t i n n i t u s i n a n a t u r a l i s t i c s e t t i n g t h e s e l e v e l s w i l l be e l e v a t e d when s u b j e c t s r a t e themselves as r e l a t i v e l y more f a t i g u e d . 78 IV Method A. S u b j e c t s S u b j e c t s were r e c r u i t e d by p u b l i c i t y t h r ough the media, and from the membership of the Vancouver T i n n i t u s S e l f - H e l p Group. I n c l u s i o n c r i t e r i a were: 1. The s u b j e c t was e x p e r i e n c i n g t i n n i t u s which c o m p l i e s w i t h the f o l l o w i n g d e f i n i t i o n : i n t e r n a l sound or sounds l o c a l i z e d i n the head and o c c u r r i n g i n the absence of e x t e r n a l a c o u s t i c s t i m u l i . The t i n n i t u s was p r e s e n t c o n t i n u o u s l y , was c o n s c i o u s l y e x p e r i e n c e d , and was not v o l u n t a r i l y p r o d u c i b l e . The sound might or might not be accompanied by o t o a c o u s t i c emi s s i o n s . 2. The t i n n i t u s had been u n r e s p o n s i v e t o m e d i c a l t r e a t m e n t . 3. The t i n n i t u s had been p r e s e n t f o r a t l e a s t t h r e e months. 4. The s u b j e c t was between th e ages of 18 and 75 y e a r s . 5. The s u b j e c t had passed a t l e a s t grade 8. 6. The s u b j e c t had e x p r e s s e d a w i l l i n g n e s s t o p a r t i c i p a t e . S u b j e c t s who had a h e a r i n g impairment s e v e r e enough t o p r e c l u d e u n d e r s t a n d i n g of normal c o n v e r s a t i o n w i t h o u t the use of a h e a r i n g a i d were e x c l u d e d (see S c r e e n i n g Form, Appendix B ) . 79 B. Measurement S i n c e the emphasis i n t h i s study was on the d i s t r e s s f e l t by t i n n i t e u r s and t h e i r s u b j e c t i v e e x p e r i e n c e of t i n n i t u s i n t e n s i t y and p i t c h , s u b j e c t i v e measures of t i n n i t u s were used. a. S e l f - R e p o r t Measures. 1. T i n n i t u s D i a r y (TD) (see Appendix C ) . T h i s was used f o r home m o n i t o r i n g of t i n n i t u s and a f f e c t l e v e l s . Each s u b j e c t was asked t o keep a t i n n i t u s d i a r y f o r one week i n t h e i r n a t u r a l environment. S u b j e c t s chose two times i n a day when they thought they would be more f a t i g u e d and two t i m e s when they thought they would be l e s s f a t i g u e d . T h i s was done i n o r d e r t o promote a l a r g e d i f f e r e n c e between h i g h and low f a t i g u e r a t i n g s . At these f o u r times s u b j e c t s r a t e d t i n n i t u s p i t c h , i n t e n s i t y , and d i s t r e s s and a l s o f a t i g u e , boredom, and a n x i e t y 2. R u s s e l l A f f e c t S c a l e (RAS) (see Appendix D). T h i s i s a t h o r o u g h l y r e s e a r c h e d i n s t r u m e n t based on a c i r c u m p l e x model of a f f e c t ( R u s s e l l , 1979). I t has p a r t i c u l a r r e l e v a n c e t o t i n n i t u s r e s e a r c h because i t i s based on two o r t h o g o n a l dimensions f o r a f f e c t ( a r o u s a l and p l e a s a n t n e s s ) which are l i k e l y t o i n f l u e n c e the l e v e l of t i n n i t u s d i s t r e s s . A l t h o u g h t h e o r i g i n a l v e r s i o n of the RAS i n c l u d e d a t h i r d d i m e n s i o n , dominance, ( R u s s e l l and Mehrabian, 1977), t h i s was found t o add l i t t l e p r e d i c t i v e power t o the s c a l e ( R u s s e l l , 1980). R u s s e l l and S t e i g e r (1982) demonstrated t h a t the RAS ( i n c l u d i n g the dominance s c a l e ) , c o u l d p r e d i c t s c o r e s on the seven s u b s c a l e s of the P r o f i l e of Mood S t a t e s (POMS) (McNair, L o r r , and Dropplernan, 1971) r e a s o n a b l y 80 w e l l . M u l t i p l e c o r r e l a t i o n s between p r e d i c t e d and a c t u a l POMS s c o r e s on the f a t i g u e - i n e r t i a and the t e n s i o n - a n x i e t y s u b s c a l e s were .72 and .81 r e s p e c t i v e l y when s u b j e c t s r a t e d the a f f e c t p o r t r a y e d by a c t o r s on a v i d e o t a p e . M u l t i p l e c o r r e l a t i o n s of .70 and .63 r e s p e c t i v e l y were o b t a i n e d when s u b j e c t s r a t e d t h e i r own a f f e c t ( R u s s e l l and S t e i g e r , 1982). Here a g a i n , the dominance dimension added l i t t l e p r e d i c t i v e power t o the r e g r e s s i o n e q u a t i o n s . In the i n t e r e s t of speed of c o m p l e t i o n of the i n s t r u m e n t , t h e r e f o r e , dominance s c a l e items were not i n c l u d e d i n the v e r s i o n of the RAS used i n t h i s s t u d y . The RAS has been shown t o have h i g h i n t e r n a l c o n s i s t e n c y ; Cronbach's c o e f f i c i e n t a l p h a was above .88 f o r each of i t s t h r e e d i m e n s i o n s ( R u s s e l l and Mehrabian, 1977). In a d d i t i o n t o i t s s a t i s f a c t o r y p s y c h o m e t r i c p r o p e r t i e s , t h e r e i s a p r a c t i c a l a t t r i b u t e which make the RAS u s e f u l i n t h i s s t u d y : i t u s u a l l y can be completed i n l e s s than two minute s . Two of the m a n i p u l a t i o n s i n t h i s s tudy take f i v e minutes each. S u b j e c t s would take a t l e a s t as l o n g as t h i s t o complete most o t h e r p o p u l a r a f f e c t s c a l e s . The RAS i s p a r t i c u l a r l y s u i t a b l e here f o r the speed w i t h which i t can be completed. The r e g r e s s i o n e q u a t i o n s d e v e l o p e d by R u s s e l l and S t e i g e r (1982, t a b l e 6) t o p r e d i c t the POMS f a t i g u e - i n e r t i a s c o r e from the RAS s c o r e s w i l l be used t o e s t i m a t e f a t i g u e as a check on the v i s u a l analogue r a t i n g of f a t i g u e . S i m i l a r l y , r e g r e s s i o n e s t i m a t e s of a n x i e t y w i l l be used t o v e r i f y the v i s u a l analogue r a t i n g s of a n x i e t y . 81 The RAS was a d m i n i s t e r e d b e f o r e and" a f t e r each e x p e r i m e n t a l m a n i p u l a t i o n . 3. V i s u a l Analogue T i n n i t u s S c a l e (VATS). T h i s i n s t r u m e n t i s d e s i g n e d t o y i e l d r a p i d r a t i n g s on d i m e n s i o n s of t i n n i t u s r e l e v a n t t o t h i s s t u d y . A v i s u a l analogue s c a l e i s a l i n e , the l e n g t h of which i s taken t o r e p r e s e n t the continuum of some e x p e r i e n c e . I t has many advantages as a method of measurement: s e n s i t i v i t y , s i m p l i c i t y , and r e l i a b i l i t y ( H u s k i s s o n , 1983). The VATS c o n s i s t s of t h r e e h o r i z o n t a l l i n e s r e p r e s e n t i n g t h r e e a s p e c t s of t i n n i t u s : d i s t r e s s , i n t e n s i t y , and p i t c h . In the l a b o r a t o r y s e c t i o n of t h i s s t u d y , the VATS was a d m i n i s t e r e d s i m u l t a n e o u s l y w i t h the RAS. In the home-monitoring s e c t i o n of t h i s s t u d y , the VATS was i n c l u d e d i n the T i n n i t u s D i a r y . 4. Focus V e r i f i c a t i o n ( F V ) . In o r d e r t o determine whether s u b j e c t s i n the t i n n i t u s f o c u s group had c o m p l i e d w i t h i n s t r u c t i o n s t o f o c u s on t h e i r t i n n i t u s , they were asked t o complete the FV-T (see Appendix E) a f t e r each phase (see E x p e r i m e n t a l D e s i g n , F i g u r e 2 ) . The FV-T r e q u i r e s s u b j e c t s t o e s t i m a t e the pe r c e n t a g e of time they spent f o c u s s i n g on t h e i r t i n n i t u s d u r i n g the t i n n i t u s f o c u s phase. The FV was s i m i l a r l y a d m i n i s t e r e d t o a n x i e t y and c o n t r o l group s u b j e c t s i n the a p p r o p r i a t e v e r s i o n (FV-Numbers and FV-Reading r e s p e c t i v e l y , see Appendices F and G). The FV-N and the FV-R d i f f e r from the FV-T o n l y i n i n s t r u c t i o n s f o r form c o m p l e t i o n t o be c o n s i s t e n t w i t h e x p e r i m e n t a l t a s k ( f o c u s s i n g on p r i n t e d numbers i n a number v i g i l a n c e t a s k , and r e a d i n g magazines, r e s p e c t i v e l y . ) F i g u r e 2 EXPERIMENTAL DESIGN Group M a n i p u l a t i o n Phases 1 A t t e n t i o n Focus '5 Adaptat i on T m m tus Focus R e v e r s a l 2 Anx1ety 15 Adaptat ion Anx i e t y (Camera + NVT) Re v e r s a l 3 Fat igue ,. Adaptat ion Fat igue (NVT) Fat igue (NVT) Fat igue (NVT) Fat igue (NVT) Fat igue (NVT) 4 C o n t r o l 15 Adaptat1 on C o n t r o l Task (Read) C o n t r o l Task (Read) C o n t r o l Task (Read) C o n t r o l Task (Read) C o n t r o l Task (Read) Durat i o n (minutes) 10 5 5 15 15 15 Phase A B C D E F Note. N = 60 NVT number v i g i l a n c e task 83 5. The H e a r i n g A b i l i t y S c a l e (HAS). T h i s b r i e f q u e s t i o n n a i r e was d e v e l o p e d f o r community s u r v e y s of h e a r i n g l o s s (see Appendix H). I t c o n s i s t s of seven s t a t e m e n t s about h e a r i n g a b i l i t y t h a t c o m p l i e d w i t h Guttman s c a l i n g i n a l a r g e demographic study ( V i t a l & H e a l t h S t a t i s t i c s , 1968). The s c o r e s range from 1 (normal h e a r i n g ) t o 8 ( p r o f o u n d h e a r i n g l o s s ) . In t h i s s t u d y h e a r i n g a b i l i t y , as e s t i m a t e d by the HAS, c o r r e l a t e d w e l l w i t h a u d i o m e t r i c a l l y d e t e r m i n e d e s t i m a t e s . b. P h y s i o l o g i c a l measure. A Sanyo Pulsemeter Model HRM-97E ( m a n u f a c t u r e r : Sanyo Canada, Toronto) was used t o t a k e p e r i o d i c h e a r t - r a t e measurements. A c c u r a c y of m o n i t o r i n g w i t h t h i s i n s t r u m e n t i s ±3%, ( e q u i v a l e n t t o ±1 b e a t ) . F i n g e r b l o o d volume v a r i e s w i t h h e a r t - b e a t which a f f e c t s l i g h t t r a n s m i s s i o n . T h i s system uses a p h o t o - e l e c t r i c c e l l c l i p p e d t o the f o u r t h f i n g e r of the s u b j e c t ' s n o n - p r e f e r r e d hand, t o e s t i m a t e h e a r t - r a t e from l i g h t t r a n s m i t t e d t h r o u g h the f i n g e r . I t was recommended as a s i m p l e , n o n - i n v a s i v e t e c h n i q u e f o r measurement of h e a r t - r a t e ( J e n n i n g s , Tahmoush, and Redmond, 1980). Readings were ta k e n e v e r y 10 seconds d u r i n g the l a s t minute of each e x p e r i m e n t a l phase (see E x p e r i m e n t a l D e s i g n , F i g u r e 2 ) . The a r i t h m e t i c mean of each such s e t of t h e s e r e a d i n g s was used i n a n a l y s e s as a measure of h e a r t - r a t e . 84 C. E x p e r i m e n t a l P r o c e d u r e and D e s i g n a. L a b o r a t o r y p r o c e d u r e . S u b j e c t s were randomly a s s i g n e d t o one of f o u r groups, each c o n s i s t i n g of 15 members. The e x p e r i m e n t a l d e s i g n i s r e p r e s e n t e d i n F i g u r e 2 and the e x p e r i m e n t a l procedure i s summarized below. S u b j e c t s were shown i n t o a q u i e t 12 f o o t x 12 f o o t room l i t by i n c a n d e s c e n t l i g h t s t o a v o i d f l u o r e s c e n t l i g h t i n g hum, and f u r n i s h e d w i t h a t a b l e and c h a i r f o r the s u b j e c t and a t a b l e and c h a i r f o r the e x p e r i m e n t e r . S u b j e c t s s i g n e d a consent form (see Appendix D). D u r i n g the 10 minutes a d a p t a t i o n phase (phase A i n F i g u r e 2) the h e a r t - r a t e sensor c l i p was a t t a c h e d t o the f o u r t h f i n g e r of the n o n - p r e f e r r e d hand. S u b j e c t s were asked t o s i t q u i e t l y w h i l e c o m p l e t i n g a T i n n i t u s Q u e s t i o n n a i r e (TQ), (see Appendix I) and the H e a r i n g A b i l i t y S c a l e . Each s u b j e c t was then i n d i v i d u a l l y a d m i n i s t e r e d one of the f o l l o w i n g e x p e r i m e n t a l m a n i p u l a t i o n s . 1. A t t e n t i o n a l f o c u s . S u b j e c t s were i n s t r u c t e d from a s c r i p t (see m a n i p u l a t i o n phase of p r o t o c o l i n Appendix J ) read by the e x p e r i m e n t e r t o f o c u s t h e i r a t t e n t i o n as e x c l u s i v e l y as p o s s i b l e on t h e i r t i n n i t u s sound and t o l i s t e n t o a l l i t s c h a r a c t e r i s t i c s f o r f i v e minutes d u r i n g which HR r e a d i n g s were taken and a t the end of which the FV-T and the RAS were a d m i n i s t e r e d . D u r i n g r e v e r s a l phase (phase C i n F i g u r e 2) s u b j e c t s were 85 asked t o t h i n k f o r f i v e minutes about a n e u t r a l s u b j e c t such as the r o u t e t o be taken when d r i v i n g home l a t e r t h a t day or what they might be h a v i n g f o r d i n n e r . The FV-T and RAS were a d m i n i s t e r e d a t the end of t h i s phase. 2. A n x i e t y i n d u c t i o n . The Number V i g i l a n c e Task (NVT) was deve l o p e d by Moran and M e f f e r d (1959) t o p r o v i d e r e s e a r c h e r s w i t h m u l t i p l e p a r a l l e l forms of e x p e r i m e n t a l t a s k s w i t h h i g h t e s t - r e t e s t r e l i a b i l i t i e s . S u b j e c t s were r e q u i r e d t o mark o f f a t a r g e t number, i d e n t i f i e d a t the b e g i n n i n g of each row of numbers, wherever i t o c c u r r e d i n t h a t row. To induce a n x i e t y , s u b j e c t s were asked t o do the NVT, w h i l e h a v i n g a v i d e o camera aimed a t them. They were in f o r m e d as f o l l o w s : "When I t u r n the v i d e o camera on, a v i d e o p i c t u r e of you w i l l be t r a n s m i t t e d t o a l a b next door, where two p s y c h o l o g i s t s w i l l observe you as you mark the numbers f o r f i v e m i n u t e s . We a r e s t a r t i n g now." In f a c t the v i d e o camera was not t u r n e d on, nor were any o b s e r v e r s p r e s e n t . HR was taken d u r i n g t h i s p e r i o d . A f t e r f i v e minutes the FV-N and RAS were a d m i n i s t e r e d . T h i s p r o t o c o l i s summarized i n Appendix K. 3. F a t i g u e i n d u c t i o n . A p i l o t s tudy on c o l l e g e u n d e r g r a d u a t e s was run t o a s s e s s the p r a c t i c a b i l i t y of i n d u c i n g f a t i g u e by means of a p r o l o n g e d number v i g i l a n c e t a s k . R e s u l t s showed t h a t t h i s was f e a s i b l e (see Appendix A ) . S u b j e c t s were asked t o do the NVT f o r 60 minutes (see Appendix L f o r d e s c r i p t i o n of p r o t o c o l ) . 4. C o n t r o l . S u b j e c t s were asked t o read N a t i o n a l 86 Geographic Magazines a f t e r b e i n g t o l d t h a t t h e r e would be no e n q u i r y or t e s t i n g of t h e i r r e a d i n g , i n o r d e r t o r e l i e v e any a n x i e t y they might have about t h i s (see p r o t o c o l i n Appendix M). They were asked t o r e c o r d the number w r i t t e n on the c o v e r of each magazine on a Reading L i s t (see Appendix N) t o a s s i s t i n v e r i f y i n g t h a t they were i n f a c t r e a d i n g magazines. b. Home-monitoring p r o c e d u r e . Each s u b j e c t was r e q u i r e d t o i d e n t i f y two t i m e s d u r i n g a t y p i c a l day when he or she f e l t most f a t i g u e d , and two t i m e s when l e a s t f a t i g u e d . These t i m e s were e n t e r e d by the e x p e r i m e n t e r i n the s u b j e c t ' s T i n n i t u s D i a r y (TD), (see Appendix C ) , and the s u b j e c t was asked t o r e c o r d i n f o r m a t i o n about the t i n n i t u s i n the t i n n i t u s d i a r y a t t h e s e four, t i m e s d a i l y f o r one week. 87 V RESULTS 1. S u b j e c t s . One hundred and twenty-seven t i n n i t e u r s were c o n t a c t e d as p o t e n t i a l s u b j e c t s ; 60 (47.3%) c o m p l i e d w i t h c r i t e r i a and were used as s u b j e c t s . Reasons f o r n o n - p a r t i c i p a t i o n of the r e m a i n i n g 67 (52.7%) a r e summarized i n Appendix 0. Of t h e s e , 44.8% f a i l e d t o meet c r i t e r i a f o r p a r t i c i p a t i o n and 55.2% d i d not p a r t i c i p a t e f o r a d m i n i s t r a t i v e r e a s o n s . P a r t i c i p a t i n g s u b j e c t s had a mean age of 53.9 y e a r s (range 30 t o 70 y e a r s ) and mean d u r a t i o n of t i n n i t u s was 11.1 y e a r s (range .6 t o 50 y e a r s ) . They had r e c e i v e d a mean of 14.5 y e a r s of e d u c a t i o n (range 8 t o 23 y e a r s ) and the male:female r a t i o was .82. In g e n e r a l s u b j e c t s had good h e a r i n g a b i l i t y as i n d i c a t e d by a mean s c o r e of 1.5 (range 1 t o 3) on the HAS. T h i s suggested t h a t , on av e r a g e , s u b j e c t s c o u l d hear and u n d e r s t a n d normal speech from a c r o s s a q u i e t room. Ta b l e 2 summarizes demographic c h a r a c t e r i s t i c s of p a r t i c i p a n t s . 2. Group E q u i v a l e n c e . In t e s t i n g f o r group e q u i v a l e n c e , no s i g n i f i c a n t d i f f e r e n c e s were found among groups. I n s p e c t i o n of Table 2 r e v e a l e d o n l y one noteworthy t r e n d r e g a r d i n g group e q u i v a l e n c e : the v a r i a t i o n i n the r a t i o of males/females i n each group. However, t h e r e a re no r e p o r t s i n the l i t e r a t u r e which f i n d T a b l e 2 Demographic C h a r a c t e r i s t i c s of S u b j e c t s L i n e was t r u n c a t e d from 139 to 132 c h a r a c t e r s . Near r e c o r d 13 page 2 l i n e 10. Group A t t e n t i o n Focus (n=15) Anx i e t y (n=15) Fat i gue (n=15) C o n t r o l (n=15) T o t a l (n=60) AGE ( y e a r s ) Mean SD Range D u r a t i o n ( y e a r s ) Mean SD Range E d u c a t i o n ( y e a r s ) Mean SD Range Sex:number (%) Ma 1 e Female R a t i o : male/female Hear i ng Abi.1 i t y Mean ( n ) b SD Range 53 .6 12.8 30-70 11.7 10.3 .6-35 14.8 3.3 12-23 3(20) 12(80) .25 1.4(13) .5 1-2 54.4 11.0 30-69 11.8 11.1 .8-40 15.2 3.2 1 1-22 8(53.3) 7(46.7) 1 . 14 1.8(14) .7 1-3 54 . 1 9 . 1 41-66 7. 1 5 . 1 1.2-20 14.0 3 . 3 9-21 6(40) 9(60) .66 1.4(14) .5 1-3 53. 7 11.3 32-65 13.8 15.1 1.1-50 14 . 1 3.4 8-21 10(66.7) 5(33.3) 2 .00 1.5(13) .8 1-3 53.9 10.8 30-70 11.1 1 1 .0 .6-50 14.5 3 . 2 8-23 27(45) 33(55) .82 1 . 5(54) .6 1-3 Note: a From H e a r i n g A b i l i t y S c a l e (range:1 normal to 8 s e v e r e d i s a b i l i t y ) b Group s i z e s d e p l e t e d by some n o n - s c a l i n g responses oo oo 89 d i f f e r e n t i a l r esponses t o t i n n i t u s between male and fema l e s . The m u l t i p l e r e g r e s s i o n a n a l y s i s , d e s c r i b e d l a t e r i n t h i s s e c t i o n , s i m i l a r l y y i e l d e d t he l o w e s t r e g r e s s i o n weight f o r sex i n p r e d i c t i n g t i n n i t u s d i s t r e s s from a number of v a r i a b l e s . A MANOVA1 2 among the f o u r groups on demographic v a r i a b l e s ( s e x , age, e d u c a t i o n , and h e a r i n g a b i l i t y ) y i e l d e d no s i g n i f i c a n t group d i f f e r e n c e , F(12,124)=1.74, n . s . 3 A MANOVA among the groups on a f f e c t - r e l a t e d v a r i a b l e s ( i n i t i a l s c o r e s on s e l f - r a t e d a n x i e t y , s e l f - r a t e d f a t i g u e , p l e a s u r e and a r o u s a l s c o r e s on the R u s s e l l A f f e c t S c a l e , and h e a r t r a t e ) y i e l d e d no s i g n i f i c a n t group d i f f e r e n c e , F(15,143)=.39, n.s. A s i m i l a r MANOVA on i n i t i a l s e l f - r a t i n g s of t i n n i t u s v a r i a b l e s ( d i s t r e s s , i n t e n s i t y , p i t c h , c o m p l e x i t y , and d u r a t i o n from o n s e t ) d i s c l o s e d no s i g n i f i c a n t group d i f f e r e n c e , F(15,143)=83, g>.64. Thus s t a t i s t i c a l e v a l u a t i o n i n d i c a t e d t h a t the groups were w e l l matched. 1 A l l MANOVAs were performed t h r o u g h BMDP4V, (D i x o n , 1981). 2 S t a t i s t i c a l a ssumptions u n d e r l y i n g MANOVA were not c r i t i c a l i n the p r e s e n t a n a l y s i s . I t i s w e l l known t h a t ANOVA pr o c e d u r e s ( i n c l u d i n g MANOVA) a r e , i n g e n e r a l , r o b u s t w i t h r e s p e c t t o v i o l a t i o n s of the n o r m a l i t y a ssumption (extended t o m u l t i v a r i a t e n o r m a l i t y i n the case of MANOVA). Wi t h r e g a r d t o the v a r i a n c e -c o v a r i a n c e a s s u m p t i o n , i t has been e s t a b l i s h e d t h a t , as i n the case of u n i v a r i a t e ANOVA (see G l a s s , Peckham & Sanders, 1972), h e t e r o g e n e i t y of c o v a r i a n c e m a t r i c e s can be t o l e r a t e d as l o n g as the n's a r e e q u a l (see e.g. H a k s t i a n , Roed, & L i n d , 1979). T h i s was the case i n t h i s s t u d y . 3 W i l k ' s Lambda c r i t e r i o n f o r t e s t i n g s i g n i f i c a n c e of MANOVAs was used th r o u g h o u t t h i s s e c t i o n . 90 3. M a n i p u l a t i o n c h e c k s . A s e r i e s of group x p e r i o d r e p e a t e d measures MANOVAs was perf o r m e d . Each MANOVA compared the t a r g e t m a n i p u l a t i o n group w i t h a group or groups which c o u l d best s e r v e as comparison. a. A t t e n t i o n Focus. A f t e r an a d a p t a t i o n p e r i o d , members of the a t t e n t i o n f o c u s group were i n s t r u c t e d t o f o c u s on t h e i r t i n n i t u s and t h e n , d u r i n g a r e v e r s a l p e r i o d , away from t h e i r t i n n i t u s . The f a t i g u e group members were r e q u e s t e d t o perfor m a number v i g i l a n c e t a s k , the c o n t r o l group members were i n s t r u c t e d t o r e a d , and thes e groups were thus a p p r o p r i a t e f o r comparison. A r e p e a t e d measures group x p e r i o d MANOVA (3x3) was performed a t tim e s A,B, & C ( a d a p t a t i o n , m a n i p u l a t i o n , and r e v e r s a l phases r e s p e c t i v e l y ) on s c o r e s f o r the t a r g e t group ( a t t e n t i o n f o c u s ) and two comparison groups (see T a b l e 3 ) . C e l l means are summarized i n Ta b l e 4. V a r i a b l e s used were FV ( f o c u s v e r i f i c a t i o n ; t he pe r c e n t a g e of time s u b j e c t s e s t i m a t e d f o c u s s i n g on t h e i r t i n n i t u s ) ; R a n x i e t y ( a n x i e t y s c o r e from the R u s s e l l A f f e c t S c a l e ) ; and R f a t i g u e ( f a t i g u e s c o r e from the R u s s e l l A f f e c t S c a l e ) . For the a t t e n t i o n f o c u s group, the o v e r a l l p e r i o d e f f e c t and the group x p e r i o d i n t e r a c t i o n were s i g n i f i c a n t , but not the o v e r a l l group e f f e c t . The o n l y v a r i a b l e c o n t r i b u t i n g s i g n i f i c a n t l y t o the e f f e c t s , as e x p e c t e d , was percentage of time f o c u s s i n g on t i n n i t u s . T a b l e 3 M a n i p u l a t i o n Check f o r A t t e n t i o n Focus. (Comparison Groups: F a t i g u e and A n x i e t y ) Repeated Measures MANOVA w i t h Subsequent ANOVAs. A n a l y s i s ( e f f e c t ) MSw df F g MANOVA at A, B,C ANOVA at A , B,C ANOVA at A, B,C ANOVA at A, B,C MANOVA at A, B.C ANOVA at A, B,C ANOVA at A, B.C ANOVA at A, B,C MANOVA at A , B.C ANOVA at A, B.C ANOVA at A, B.C ANOVA at A, B.C (group) (FV) (R anxie (R f a t i g u e ) ( p e r i o d ) (FV) (R f a t i g u e ) ' * ' ( p e r i o d x group) (FV) , (R a n x i e t y ) ? " 6,80 2 .02 > .07 7,243.76 2, 42 4 .75 < .01 .07 2,42 . 12 > .88 .53 2,42 .96 > . 39 6,37 8 . 20 < .01 1 1 .552.6 2,41 19 .87 < .01 . 19 2,41 3 . 21 > .05 . 10 2,41 1 . 10 > .34 12, 74 10 .77 < .01 8,479.61 4,82 24 . 81 < .01 . 12 4,82 1 . 95 > . 1 1 . 18 4,82 2. . 30 > .07 Note: a MSb f o r treatments i s r e p r o d u c i b l e from F x MSw b T w o - t a i l e d p r o b a b i l i t y c U s i n g W i l k ' s Lambda c r i t e r i o n d Scores from R u s s e l l A f f e c t S c a l e T a b l e 4 C e l l Means of Dependent V a r i a b l e s Phase Measure Group A t t e n t i o n Focus A n x i e t y F a t i g u e C o n t r o l Focus V e r i f i c a t i o n A n x i e t y * 1 . R anxiety'*' F a t i gue® , R f a t i gue f Heart R a t e ^ 56 .60 (37 .89) 54 . 33 (35 .04) 64 .00 (32 .47) 63 .73 (33 .91) 3 .20 ( 2. 27) 3 . 13 ( 2 .42) 3 . 27 ( 2 . 77) 3 .60 ( 1 .92) .01 ( 47) . 10 ( .49) - . 13 ( .54) .01 ( .43) 2 .80 ( 2. 21) 3. .31 ( 1 .88) 2 .47 ( 1 . 92) 2 .47 ( 1 .60) - . 19 ( • .40) , 29 ( .46) - .03 ( .44) - .06 ( .46) 78 .50 (10. .66) 75, ,09 ( 9 . 19) 74 .96 ( 9 .95) 74 .60 ( 9 . 29) Focus V e r i f i c a t i o n - 91 .07 ( 9 . 29) 1 1 .07 (23 .05) 16 .60 (27 .62) 29 .20 (31 .90) Anx i e t y 3 .67 ( 2 . 16) 3 .07 ( 1 • 71) 3 .80 ( 2 .24) 3 .67 ( 1 .68) R a n x i e t y .21 ( .62) . 17 ( . 59) .04 ( .49) .02 ( . 39) Fat i gue 2 .80 ( 1 . .94) 3 .40 ( 2 .06) 2 .60 ( 1 .68) 2 .60 ( 1 .45) R f a t i g u e .09 ( , 35) - . 15 ( .55) - .27 ( • 41) . 10 ( .59) Heart Rate 73 .46 ( 9, , 80) 80 .06 (11 .06) 77 .62 (10 .32) 71 .00 ( 9 .48) Focus V e r i f i c a t i o n 32 . 33 (28 .90) 20 .53 (22 .46) 28 .87 (34 .01) 27 .00 (27 31) Anx i e t y 2 .87 ( 1 .85) 2 .67 ( 1. 68) 3 .40 ( 2 . 29) 2 .93 ( 1. 62) R a n x i e t y - .03 ( . 58) .03 ( . 44) .06 ( . 59) - .04 ( . 39) Fat igue 2 .80 ( 1 .93) 3, . 20 ( 1. 82) 3 . 13 ( 1 81) 2 . 53 ( 1. , 25) R f a t i g u e - .08 ( . 46) . 25 ( . 39) - .09 ( .65) . 14 ( . 59) Heart Rate 73 . 12 ( 9. 51) 72, .67 (10. .94) 76 .96 (11 .49) 69 .98 (10. 57) (cont i nued) T a b l e 4 ( c o n t ' d ) C e l l Means of Dependent V a r i a b l e s Phase Measure Group A t t e n t i o n Focus A n x i e t y F a t i g u e C o n t r o l D Focus V e r i f i c a t i o n 23 20 (31 75) 23 80 (23 88) Anx i e t y 3 27 ( 1 94) 3 13 ( 1 41) R a n x i e t y 32 61) - 07 45) Fat igue 3 93 ( 2 43) 2 87 ( 1 51) R f a t i g u e 15 72) 22 48) Heart Rate 74 02 ( 9 31) 68 97 ( 9 51) E Focus V e r i f i c a t i o n 20 40 (31 61) 20 20 (23 20) Anx i e t y 3 87 ( 1 92) 3 13 ( 1 64) R a n x i e t y 42 56) - 08 54) Fat i gue 4 87 ( 2 03) 3 80 ( 1 90) R f a t i g u e 52 71) 47 50) Heart Rate 71 25 ( 7 97) 66 75 ( 10 68) F Focus V e r i f i c a t i o n 22 33 (30 46) 19 13 (22 21) A n x i e t y 4 07 ( 1 94) 3 40 ( 1 59) R a n x i e t y 72 64) 13 59) Fat i gue 5 67 ( 2 25) 3 93 ( 2 19) R f a t i g u e 73 66) 70 55) Heart Rate 71 35 ( 8 41) 66 25 ( 9 82) Note: a (Standard d e v i a t i o n s ) b S e l f - r a t i n g of % time f o c u s s e d on t i n n i t u s c S e l f - r a t i n g of a n x i e t y ; range 1-9 d A n x i e t y e s t i m a t e from R u s s e l l A f f e c t S c a l e ; range 6-54 e S e l f - r a t i n g of f a t i g u e ; range 1-9 f F a t i g u e e s t i m a t e from R u s s e l l A f f e c t S c a l e ; range 6-54 g Beats per minute 94 The MANOVA group e f f e c t m i s s e d s i g n i f i c a n c e 1 F(6,80)=2.02, £>.07. However, the p e r i o d e f f e c t was h i g h l y s i g n i f i c a n t , F (6,37)=8.20, g<.000l. Subsequent ANOVAs on the dependent v a r i a b l e s r e v e a l e d a h i g h l y s i g n i f i c a n t p e r i o d e f f e c t f o r FV, F(2,42)=19.87, p_<.0001, but not f o r R a n x i e t y , F ( 2 , 42) =3. 21 , n.s., nor R f a t i g u e , F(2,42)=1.14,n.s.* There was a h i g h l y s i g n i f i c a n t p e r i o d x group i n t e r a c t i o n e f f e c t on the MANOVA, F(12,74) = 1 0.77, 2 < - 0 0 0 1 - 0 n c e a g a i n subsequent ANOVAs on the dependent v a r i a b l e s showed h i g h s i g n i f i c a n c e f o r FV, F(4,82)=24.81, p<.000l; but not f o r R a n x i e t y F(4,82)=1.95, n.s.; nor the R f a t i g u e , F(4,82)=2.30, n.s. To d e t e r m i n e a t which phases s i g n i f i c a n t e f f e c t s o c c u r r e d , s e p a r a t e one way MANOVAs were done f o r each phase, A,B, and C u s i n g the v a r i a b l e s FV, R a n x i e t y , and R f a t i g u e . The c r i t i c a l a l e v e l was s e t a t .05/3=0.017 a f t e r B o n f e r r o n i a d j u s t m e n t . 5 The group e f f e c t was s i g n i f i c a n t a t phase B, F(6 ,80) = 11.27, p_<.000l; but not a t A, F(6,80)=.58,n.s.; nor a t C, F(6,80)=.46,n.s. Subsequent ANOVAs were performed a t B on each v a r i a b l e " Throughout the f o l l o w i n g r e p e a t e d measures ANOVAs, the Gree n h o u s e - G e i s s e r adjustment was used when the c o r r e l a t i o n m a t r i x was s i g n i f i c a n t l y d i f f e r e n t from s p h e r i c a l form by B a r t l e t t ' s t e s t of s p h e r i c i t y . The Greehnouse-Geisser adjustment compensates f o r the f a c t t h a t such t e s t s t e n d t o be too l i b e r a l i n some c a s e s by r e d u c i n g the degrees of freedom by a s o - c a l l e d e p s i l o n f a c t o r (Winer, 1962). *• In o r d e r t o c o n t r o l f o r the p o s s i b i l i t y of i n f l a t i n g type I e r r o r r a t e s due t o the number of t e s t s b e i n g performed i n th e s e and i n f u r t h e r s u b - a n a l y s e s , B o n f e r r o n i a d j u s t m e n t s were made t o the c r i t i c a l l e v e l s f o r j u d g i n g s i g n i f i c a n c e ( H a r r i s , 1975). 95 s e p a r a t e l y t o d e t e r m i n e which c o n t r i b u t e d s i g n i f i c a n t l y t o the group e f f e c t . C r i t i c a l a l e v e l was s e t a t .05/9=.0056. The ANOVA f o r FV was s i g n i f i c a n t , F(2,42) =38.29,p_<.0001 ; but R a n x i e t y was n o t , F(2,42)=.65, n.s.; nor was R f a t i g u e , F(2,42)=2.50, n.s. In o r d e r t o d i s c e r n which i n t e r g r o u p d i f f e r e n c e s c o n t r i b u t e d t o the s i g n i f i c a n t group e f f e c t f o r FV a t B, Tukey t e s t s ( h o n e s t l y s i g n i f i c a n t d i f f e r e n c e w i t h s t u d e n t i z e d range, g) were performed w i t h c r i t i c a l a l e v e l s e t a t .0056. While t h e r e were s i g n i f i c a n t d i f f e r e n c e s between the a t t e n t i o n f o c u s and f a t i g u e group s c o r e s , g( 3, 42 ) = 1 1 . 56, p_<.005; and a l s o between a t t e n t i o n f o c u s and c o n t r o l groups, g( 3,42) =9.61 , p_<.005; no s i g n i f i c a n t d i f f e r e n c e was found between the f a t i g u e and c o n t r o l groups, g( 3,42) = 1.96, n.s. These a n a l y s e s i n d i c a t e d t h a t the e x p e r i m e n t a l m a n i p u l a t i o n of t i n n i t u s f o c u s was s u c c e s s f u l l y a c h i e v e d . The FV s c o r e s f o r the a t t e n t i o n f o c u s group were s i g n i f i c a n t l y h i g h e r than f o r the comparison groups a t the e x p e c t e d phase of the m a n i p u l a t i o n (see F i g u r e 3 ) . A n x i e t y and f a t i g u e s c o r e s d i d not v a r y s i g n i f i c a n t l y e i t h e r between groups or a c r o s s time i n t h e s e a n a l y s e s . Thus, the a t t e n t i o n a l focus m a n i p u l a t i o n d i d not a f f e c t measures of a n x i e t y or f a t i g u e i n these s u b j e c t s . b. A n x i e t y A r e p e a t e d measures group x p e r i o d MANOVA (2x3) was performed a t t i m e s A, B, and C on s c o r e s of the a n x i e t y group and a comparison group ( f a t i g u e group) (see T a b l e 5 ) . The 100 CO o CO O £ C CO © oo 80 70 60 50 40 30 20 10-0 -• Attention Focus O Anxiety • Fatigue • Control —r -A B —r -c — r -D Phase Fig. 3. Mean focus v e r i f i c a t i o n over experimental phases. Table 5 M a n i p u l a t i o n Check f o r A n x i e t y . (Comparison Group: F a t i g u e ) Repeated Measures MANOVA w i t h Subsequent ANOVAs. A n a l y s i s ( e f f e c t ) MSw df F g MANOVA at A,B,C (group) 2, 27 . 74 > .48 ANOVA at A.B.C ( a n x i e t y ) ^ 6 .40 1 , 28 .69 > .41 ANOVA at A.B.C (R a n x i e t y ) 2 .70 1 , 28 . 39 > .53 MANOVA at A.B.C (per i od) 4 , 25 .88 > , .49 ANOVA at A,B,C ( a n x i e t y ) 1 . .21 2, 27 . 58 > . .56 ANOVA at A.B.C (R a n x i e t y ) .09 2, 27 1 . 24 > . . 30 MANOVA at A , B , C ( p e r i o d x group) 4 , 25 1 .02 > . 41 ANOVA at A.B.C ( a n x i e t y ) 90 2, 27 . 29 > . 74 ANOVA at A.B.C (R a n x i e t y ) 14 2, 27 2 .03 15 Note: a MSb f o r treatments i s r e p r o d u c i b l e from F x MSw b T w o - t a i l e d p r o b a b i l i t y c U s i n g W i l k ' s Lambda c r i t e r i o n d Scores from R u s s e l l A f f e c t S c a l e 98 f a t i g u e group was an a p p r o p r i a t e comparison group because s u b j e c t s i n t h i s group r e c e i v e d the same e x p e r i m e n t a l t r e a t m e n t as s u b j e c t s i n the a n x i e t y group ( i . e . the number v i g i l a n c e t a s k ) except f o r the a n x i e t y i n d u c t i o n supplement f o r a n x i e t y group members o n l y . C e l l means a r e summarized i n Ta b l e 4. V a r i a b l e s used were two measures of a n x i e t y l e v e l : a n x i e t y ( s e l f - r a t e d a n x i e t y on a 1-9 s c a l e ) and R a n x i e t y . The MANOVA group e f f e c t , p e r i o d e f f e c t , and group x p e r i o d i n t e r a c t i o n were a l l n o n - s i g n i f i c a n t ( r e s p e c t i v e l y F(2,27)=.74, n.s.; F(1.81,50.70)=.44,n.s.; and F(4,25)=1.02, n . s . ) . Thus the a n x i e t y m a n i p u l a t i o n d i d not a f f e c t the measures of a n x i e t y s i g n i f i c a n t l y . c. F a t i g u e A n a l y s i s of da t a f o r the f a t i g u e m a n i p u l a t i o n showed t h a t t h e r e was a s i g n i f i c a n t time e f f e c t ( f a t i g u e r a t i n g s i n c r e a s e d s i g n i f i c a n t l y ) but group and i n t e r a c t i o n e f f e c t s were not s i g n i f i c a n t . A r e p e a t e d measures group x p e r i o d MANOVA (2x6) was run a t tim e s A,B,C,D,E, and F on s c o r e s f o r the f a t i g u e group and a comparison group ( c o n t r o l g r o u p ) . Two measures of f a t i g u e l e v e l were used: f a t i g u e ( s e l f - r a t e d f a t i g u e on a 1-9 s c a l e ) and R f a t i g u e . R e s u l t s a r e g i v e n i n Table 6 and c e l l means i n Ta b l e 4. The MANOVA f o r group e f f e c t was not s i g n i f i c a n t , F(2,27)=2.02, n.s.; but the f i n d i n g was h i g h l y s i g n i f i c a n t f o r the p e r i o d e f f e c t , F(10,19)=7.52, p_<« 0°0 1' Subsequent ANOVAs on T a b l e 6 M a n i p u l a t i o n Check f o r F a t i g u e . (Comparison Group: C o n t r o l ) Repeated Measures MANOVA wi t h Subsequent ANOVAs and MANOVAs at Each Phase. A n a l y s i s ( e f f e c t ) MSw df F C E b MANOVA at A-F (group) 2,27 2 .02 > . 15 ANOVA at A-F ( f a t i g u e ) ^ 24.94 1 , 28 1 .67 > . 20 ANOVA at A-F (R f a t i g u e ) .41 1 , 28 .30 > . 58 MANOVA at A-F (per i od) 10, 19 7 . 52 < .0001 ANOVA at A-F ( f a t i gue) 27.98 5, 24 9 . 37 < .0001 ANOVA at A-F (R f a t i g u e ) 3 . 17 5,24 1 1 .84 < .0001 MANOVA at p e r i o d A 2, 27 .01 > .98 MANOVA at p e r i o d B 2,27 2 . 36 > . 1 1 MANOVA at p e r i o d C 2,27 2 .75 > .08 MANOVA at p e r i o d D 2, 27 2 . 12 > . 13 MANOVA at p e r i o d E 2,27 1 .22 > .30 MANOVA at p e r i o d F 2, 27 2 .47 > . 10 MANOVA at A-F ( p e r i o d x group) 10, 19 2 .01 > .09 ANOVA at A-F ( f a t igue) 3.47 5, 24 1 . 53 < .04 ANOVA at A-F (R f a t i g u e ) . 22 5,24 1 .91 < . 13 Note: a MSb f o r treatments i s r e p r o d u c i b l e from F x MSw b T w o - t a i l e d p r o b a b i l i t y c U s i n g W i l k ' s Lambda c r i t e r i o n d Scores from R u s s e l l A f f e c t S c a l e 100 the dependent v a r i a b l e s showed a h i g h l y s i g n i f i c a n t p e r i o d e f f e c t f o r both f a t i g u e and R f a t i g u e ; r e s p e c t i v e l y F(5,24)=9.37, 2<.0001; and F(5,24) = 11 .84,p_<.0001 . The p e r i o d x group i n t e r a c t i o n m i ssed s i g n i f i c a n c e f o r the MANOVA, F(10,19)=2.01,2>.09. Se p a r a t e one way MANOVAs were done f o r each phase A through F, w i t h dependent measures f a t i g u e and R f a t i g u e . None of t h e s e reached s i g n i f i c a n c e (see T a b l e 6 ) . d. Heart r a t e An ANOVA was performed on h e a r t r a t e (HR) f o r each group d u r i n g the a d a p t a t i o n phase (phase A ) . The mean HR was computed from samples c o l l e c t e d d u r i n g the f i r s t , m i d d l e , and l a s t minute of the a d a p t a t i o n phase. These i n i t i a l HRs a c r o s s groups were not s i g n i f i c a n t l y d i f f e r e n t , F(3,56)=.70,n.s. ( i ) HR - a t t e n t i o n a l f o c u s Mean HR 6 was compared between the a t t e n t i o n f o c u s group and comparison groups ( t h e f a t i g u e group i n which a t t e n t i o n was f o c u s e d on a number v i g i l a n c e t a s k , and the c o n t r o l group where f o c u s was on r e a d i n g m a g a z i n e s ) . A r e p e a t e d measures ANOVA was performed on mean HR f o r phases A,B, and C. There was a h i g h l y s i g n i f i c a n t o v e r a l l time e f f e c t , F (2 ,84) =7 .1 1 , p_<.00l; and a h i g h l y s i g n i f i c a n t o v e r a l l p e r i o d x group i n t e r a c t i o n , s C e l l HR means are t a b u l a t e d i n T a b l e 4 and p l o t t e d on F i g u r e 4. Mean Heart Rate (b.p.m.) a> o tn __L_ -«4 O _ L _ -si O l 00 o CD CM oo •t> s n B) 3 3* n> to M rt i-( to rt '—* cr u •a 3 —* CO o < (6 (I) ro <i H-3 ft 3 rt 0) t—' T) 3" 09 CO ro CO 04 • m 4 / • • • O • o n > > onti 9 O nxl< tter c 9 «< o 3 -n o o c 01 101 102 F(4,84)=6.86, jk.0001. T h i s a n a l y s i s was f o l l o w e d by ANOVAs a t each of the t h r e e phases w i t h s i g n i f i c a n c e l e v e l s s e t a t a=.05/3=.0l7 by B o n f e r r o n i a d j u s t m e n t . None of t h e s e ANOVAs was s i g n i f i c a n t (see T a b l e 7 ) . The group e f f e c t d i d not rea c h s i g n i f i c a n c e , F(2,42)=.89, n.s. These a n a l y s e s i n d i c a t e d t h a t a l t h o u g h t h e r e was a s t r o n g group x p e r i o d i n t e r a c t i o n f o r HR when a l l time p o i n t s were i n c l u d e d i n one a n a l y s i s , t h e r e was no one phase a t which groups d i f f e r e d s i g n i f i c a n t l y . ( i i ) HR - a n x i e t y A r e p e a t e d measures ANOVA (see Ta b l e 7) f o r phases A,B, and C was performed on HR f o r the a n x i e t y group and i t s comparison group ( f a t i g u e g r o u p ) . There was a s t r o n g p e r i o d e f f e c t , F(2 , 56)=4.93, p_<.0l. The l i n e a r component of the cur v e d e s c r i b i n g HR over time was n o n - s i g n i f i c a n t , F(1,28)=.02, n.s. T h i s was not unexpected g i v e n the ABA d e s i g n of the m a n i p u l a t i o n f o r a n x i e t y i . e . a d a p t a t i o n , a n x i e t y i n d u c t i o n , f o l l o w e d by a n x i e t y r e v e r s a l ( d e b r i e f i n g ) . Thus the q u a d r a t i c component of t h i s c u r v e was s a l i e n t and s t a t i s t i c a l l y s i g n i f i c a n t , F (1 , 28) = 1 4 . 1 9, p_<.001. The i n t e r a c t i o n e f f e c t between t h i s q u a d r a t i c component of HR over time and group was a l s o s i g n i f i c a n t , F (1 , 28 ) =4 . 72 , p_<.05, a l t h o u g h the o v e r a l l i n t e r a c t i o n e f f e c t m i s s e d s i g n i f i c a n c e , F(2,56)=2 .81 , p_<.07. In or d e r t o i n v e s t i g a t e d u r i n g which phases s i g n i f i c a n t d i f f e r e n c e s i n HR between groups were p r e s e n t , t - t e s t s were done a t each of the t h r e e phases w i t h a s i g n i f i c a n c e l e v e l s s e t more s t r i n g e n t l y by B o n f e r r o n i adjustment to .05/3=0.017. The group d i f f e r e n c e T a b l e 7 Repeated Measures ANOVAs on Heart Rate and Subsequent ANOVAs or j t - t e s t s at Each Phase M a n i p u l a t i o n (Comparison c L Groups) A n a l y s i s ( e f f e c t ) MSw df F p_ A t t e n t i o n Focus ANOVA at A,B,C ( p e r i o d ) 86.47 2,84 7.1 1 <.001 ( F a t i g u e , C o n t r o l ) ANOVA at A 69.61 2,42 .70 >.50 ANOVA at B 167.98 2,42 1.72 >.19 ANOVA at C 183.31 2,42 1.64 >.20 ANOVA at A,B,C (group) 254.03 2,42 .89 >.41 ANOVA at A.B.C ( p e r i o d 83.44 4,84 6.86 <.0001 x group) A n x i e t y ANOVA a t A,B,C ( p e r i o d ) 87.65 2,56 4.93 <.01 ( F a t i g u e ) t - t e s t at A .13 28 .01 >.50 j t - t e s t at B 44.66 28 4.20 <. 05 t - t e s t at C 138.06 28 12.39 <.001 ANOVA at A,B,C (group) 7.40 1,28 .03 >.86 [ p e r i o d 87.65 2,56 2.81 >.08 x group) F a t i g u e ANOVA at A-F ( p e r i o d ) 208.33 5,140 14.27 <.001 ( C o n t r o l ) t - t e s t at A .97 28 .10 >.05 328.77 28 33.18 <.001 365.49 28 33.18 <.001 191.32 28 20.34 <.001 151.91 28 16.32 <.001 195.69 28 21.53 <.001 (group) 1024.12 1,28 2.05 >.16 ( p e r i o d 42.07 5,140 2.88 <.05 x group) ANOVA at A, B, C t • t t - t e s t at B t - t e s t at C t - t e s t at D t - t e s t at E t - t e s t at F ANOVA at A-•F ANOVA at A-•F o Note: a MSb f o r treatments i s r e p r o d u c i b l e from F x MSw b T w o - t a i l e d p r o b a b i l i t y c U s i n g W i l k ' s Lambda c r i t e r i o n 104 was n o n - s i g n i f i c a n t d u r i n g the a d a p t a t i o n phase, t(28)=.12, n.s.; missed s i g n i f i c a n c e by t h i s c r i t e r i o n d u r i n g the m a n i p u l a t i o n phase, t(28)=2.05, p_<.05; and was s i g n i f i c a n t d u r i n g the r e v e r s a l phase, t(28)==3.52, p<.001. The group e f f e c t on HR missed s i g n i f i c a n c e , F(1,28)=.03, 2<.8 6. These r e s u l t s a r e graphed i n F i g u r e 4. Group HR means were v e r y s i m i l a r a t a d a p t a t i o n phase. HR f o r the a n x i e t y group exceeded the HR f o r the comparison group d u r i n g the a n x i e t y phase; and then dropped s i g n i f i c a n t l y below HR f o r the comparison ( f a t i g u e ) group d u r i n g the r e v e r s a l phase. In g e n e r a l t h e s e a n a l y s e s i n d i c a t e d t h a t when a n x i e t y l e v e l was m a n i p u l a t e d , both p e r i o d and p e r i o d x group i n t e r a c t i o n s d i s p l a y e d s i g n i f i c a n t HR e f f e c t s . HR s c o r e s were s i g n i f i c a n t l y h i g h e r f o r the f a t i g u e group a t r e v e r s a l phase and missed s i g n i f i c a n c e a t the m a n i p u l a t i o n phase. ( i i i ) HR - f a t i g u e Mean HRs were compared f o r f a t i g u e and c o n t r o l groups a c r o s s phases A t h r o u g h F by means of a r e p e a t e d measures ANOVA, (see T a b l e 7 ) . A h i g h l y s i g n i f i c a n t p e r i o d e f f e c t was found, F(5,140)=14.27 2<.001, and a l s o a s i g n i f i c a n t p e r i o d x group i n t e r a c t i o n F(5,140)=2.88, p<.05. There was a s t r o n g l i n e a r component i n HR change, F (1 , 28 ) =35. 93 , p_<.000l, but not i n the i n t e r a c t i o n e f f e c t , F(1,28)=.94, n.s. However, t h e r e was a 105 s i g n i f i c a n t q u a d r a t i c p e r i o d x group i n t e r a c t i o n , F(1,28)=8.25, p/c.01. When thes e d a t a were r e - a n a l y s e d over phases B through F (the m a n i p u l a t i o n p h a s e s ) , the o v e r a l l and q u a d r a t i c i n t e r a c t i o n e f f e c t s d i s a p p e a r e d , whereas the s t r o n g o v e r a l l and l i n e a r components of the p e r i o d e f f e c t p e r s i s t e d . To dete r m i n e a t which phases t h e r e were s i g n i f i c a n t d i f f e r e n c e s between groups, t - t e s t s were performed a t each phase w i t h s i g n i f i c a n c e l e v e l s s e t a t a=.05/6=.008 ( B o n f e r r o n i a d j u s t m e n t ) . Group d i f f e r e n c e s were s i g n i f i c a n t f o r each phase except phase A, p_<.00l. H e a r t -r a t e was c o n s i s t e n t l y and s i g n i f i c a n t l y h i g h e r f o r the f a t i g u e group than f o r the c o n t r o l group. In summary i t was found t h a t d u r i n g the p o s t - a d a p t a t i o n ( i . e . the m a n i p u l a t i o n ) phases B thr o u g h F, HR changed (decreased) s i g n i f i c a n t l y and l i n e a r l y . At each such phase HR was s i g n i f i c a n t l y h i g h e r f o r the f a t i g u e group than f o r the c o n t r o l group (see F i g u r e 4 ) . 4. H y p o t h e s i s T e s t i n g . Hypotheses were t e s t e d by comparing the v a l u e s of the t i n n i t u s v a r i a b l e s ( d i s t r e s s , i n t e n s i t y , and p i t c h ) f o r the a p p r o p r i a t e e x p e r i m e n t a l groups a f t e r the v a r i o u s e x p e r i m e n t a l m a n i p u l a t i o n s i n r e p e a t e d measures MANOVAs. When a MANOVA was s i g n i f i c a n t , the r e s u l t was a n a l y s e d f u r t h e r w i t h ANOVAs on each of the t i n n i t u s v a r i a b l e s ( p i t c h , i n t e n s i t y , and d i s t r e s s ) t o i d e n t i f y the source of the m u l t i v a r i a t e e f f e c t . The s i g n i f i c a n c e l e v e l was made more s t r i n g e n t by B o n f e r r o n i adjustment t o a=.05/3=.017 t o c o n t r o l f o r i n f l a t e d t y pe I e r r o r r a t e s . C e l l means f o r t i n n i t u s v a r i a b l e s a re summarized i n 106 T a b l e 8. a. A t t e n t i o n f o c u s The outcome on thes e v a r i a b l e s f o r the a t t e n t i o n f o c u s group was compared w i t h two comparison groups over the f i r s t t h r e e phases A,B, and C (see T a b l e 9 and F i g u r e s 5,6, and 7 ) . In one comparison group s u b j e c t s were r e q u i r e d t o f o c u s on a number v i g i l a n c e t a s k ( f a t i g u e group) and i n the second on r e a d i n g ( c o n t r o l g r o u p ) . The MANOVA d i d not y i e l d s i g n i f i c a n t o v e r a l l group d i f f e r e n c e s , F(6,80)=.59, n.s. There was a s i g n i f i c a n t p e r i o d e f f e c t F (6,37) =3.26, p_<.01. ANOVAs on i n d i v i d u a l v a r i a b l e s were performed. T i n n i t u s d i s t r e s s d i d not c o n t r i b u t e s i g n i f i c a n t l y i n the a t t e n t i o n f o c u s m a n i p u l a t i o n t o the o v e r a l l time e f f e c t , F(1.48,62.35)=.00, n.s., and n e i t h e r d i d t i n n i t u s p i t c h , F(1.58,66.49)=1.60, n.s. The e f f e c t of t i n n i t u s i n t e n s i t y was h i g h l y s i g n i f i c a n t , F(1.93,80.86)=7.59, P_<.001. When a t t e n t i o n was f o c u s s e d on t i n n i t u s by the s u b j e c t s i n the a t t e n t i o n f o c u s group d u r i n g phase B, t h i s caused a s i g n i f i c a n t i n c r e a s e i n mean t i n n i t u s i n t e n s i t y compared t o a b a s e l i n e l e v e l (phase A ) . When a t t e n t i o n was d i r e c t e d away from the t i n n i t u s d u r i n g phase C, t i n n i t u s i n t e n s i t y dropped s i g n i f i c a n t l y (see F i g u r e 6 ) . T i n n i t u s i n t e n s i t y f o r the comparison groups ( f a t i g u e and c o n t r o l ) , d i d not change i n t h i s way. I n s t e a d , t h e r e was a d e c r e a s i n g t r e n d from phase A, t o B, t o C f o r thes e s u b j e c t s . The p e r i o d x group i n t e r a c t i o n was a l s o s i g n i f i c a n t , T a b l e 8 C e l l Means of T i n n i t u s Measures Phase Measure Group A t t e n t i o n Focus A n x i e t y F a t i g u e C o n t r o l A T i n n i t u s d i s t r e s s 3 87 (2 50) 5 00 (2 67) 3 87 ( 1 64) 4 20 (2 21) i n t e n s i t y c 4 53 (2 23) 5 80 (2 15) 4 93 (2 15) 5 40 (2 10) ir p i tch<*- 4 80 (2 48) 6 27 (2 34) 5 73 (2 12) 6 00 (2 04) B T i nn i tus d i s t r e s s 4 27 (2 43) 4 47 (2 56) 3 87 (2 13) 3 73 (2 28) i ntens i t y 5 80 (2 81) 5 13 (2 26) 4 13 (2 23) 4 53 ( 1 96) p i t c h 5 60 (2 56) 5 87 (2 64) 4 67 (2 13) 5 33 (2 16) C T i n n i tus d i s t r e s s 3 80 (2 11) 4 40 (2 56) 4 47 (2 33) 3 67 (2 06) •I i ntens i t y 4 07 (2 09) 5 20 (2 65) 4 13 ( 1 89) 3 73 ( 1 91) i i p i t c h 4 87 (2 42) 6 33 (2 23) 4 87 (2 39) 5 67 ( 1 95) D T i nni tus d i s t r e s s 3 93 (2 22) 3 67 (2 16) II i ntens i t y 4 13 (2 07) 4 00 ( 1 93) " p i t c h 5 13 (2 36) 5 40 (2 50) E T i nn i t us d i s t r e s s 4 47 (2 17) 3 40 (2 03) n i ntens i t y 4 80 (2 21) 3 80 ( 1 86) II p i t c h 5 20 (2 11) 5 20 (2 31) F T i nn i t us d i s t r e s s 4 60 (2 13) 3 53 (2 13) it i ntens i t y 4 93 (2 19) 3 87 (2 00) " p i t c h 5 47 (2 00) 5 47 (2 17) Note: a ( S t a n d a r d d e v i a t i o n s ) b S e l f - r a t i n g of t i n n i t u s d i s t r e s s ; range 1-9 c S e l f - r a t i n g of t i n n i t u s i n t e n s i t y ; range 1-9 d S e l f - r a t i n g of t i n n i t u s p i t c h ; range 1-9 T a b l e 9 Repeated Measures MANOVA on T i n n i t u s V a r i a b l e s f o r A t t e n t i o n Focus M a n i p u l a t i o n w i t h Subsequent ANOVAs. (Comparison Groups: F a t i g u e and C o n t r o l ) A n a l y s i s ( e f f e c t ) T i n n i t u s Measure a. MSw df F e: E b MANOVA at A.B.C (group) d, i , p 6,80 . 59 > . 73 ANOVA a t A,B,C d .45 2,42 .04 > .96 ANOVA at A,B,C i 1 .83 2,42 . 17 > .84 ANOVA at A, B.C P 5 .01 2,42 .38 > .68 MANOVA at A (group) d, i ,p 6,80 .49 > .81 ANOVA at A d .56 2,42 . 12 > .88 ANOVA at A i 2 .82 2,42 .60 > .55 ANOVA at A P 5 .96 2,42 1 .21 > .31 MANOVA at B (group) d, i , p 6,80 1 .04 > .40 ANOVA at B d 1 . 16 2,42 . 22 > .80 ANOVA at B i 1 1 . 36 2,42 2 .04 > . 14 ANOVA at B P 3 .47 2,42 .66 > . 52 MANOVA a t C (group) d, i , p 6,80 .87 > .52 ANOVA at C d 2 .76 2,42 . 59 > . 56 ANOVA at C i .69 2,42 . 18 > .83 ANOVA at C P 3 .20 2,42 .63 > . 53 MANOVA a t A.B,C (per i od) d, i , p 6,37 3 . 26 < .01 ANOVA a t A,B.C d .01 1 .48,62.35^ .00 > .98 ANOVA at A.B.C i 12 .65 1 .93,80.86® 7 .59 < .001 ANOVA at A.B.C P 1 . 83 1 .58,66.49 1 .60 > .20 MANOVA a t A.B.C ( p e r i o d x group) d, i , p 12,74 2 . 19 < .02 ANOVA a t A,B.C d 2 .01 2.97,62.35^- 1 .82 > .31 ANOVA at A.B.C i 6 . 52 3.85,80.86** 3 .91 < .01 ANOVA at A.B.C P 3 . 81 3. 17,66.49* 3 . 34 < .05 Note: a MSb f o r treatments i s r e p r o d u c i b l e from F x MSw b T w o - t a i l e d p r o b a b i l i t y l _ i c Using W i l k ' s Lambda c r i t e r i o n O 00 d D i s t r e s s , i n t e n s i t y , p i t c h e A f t e r Greenhouse-Geisser adjustment Fig. 5. Mean distress ratings over experimental phases. 6.5 Fig. 7. Mean tinnitus pitch ratings over experimental phases. 112 F(12,74)=2.19, p_<.05. T h i s was probed f u r t h e r w i t h r e p e a t e d measure ANOVAs on each v a r i a b l e (see Ta b l e 9 ) . The p e r i o d x group i n t e r a c t i o n f o r t i n n i t u s i n t e n s i t y had a s i g n i f i c a n t b e a r i n g on the o v e r a l l p e r i o d x group i n t e r a c t i o n F(3.85,80.86)=3.91 , p_<.007. T i n n i t u s d i s t r e s s was non-s i g n i f i c a n t , F(2.97,62.35)=1.19, n.s.; and t i n n i t u s p i t c h missed s i g n i f i c a n c e , F(3.17,66.49)=3.34, p_<.02 ( a f t e r s e t t i n g a t o .05/3=.0167 by B o n f e r r o n i a d j u s t m e n t ) . To f o l l o w up on the r e p e a t e d measures MANOVAs d i s c u s s e d above, a o n e - f a c t o r (group) MANOVA was done a t each phase (see T a b l e 9 ) . None was s i g n i f i c a n t (at phase A, F(6,80)=.49, n.s.; at phase B, F(6,80)=1.04, n.s.; and a t phase C, F(6,80)=.87, n . s ) . Thus, t h e r e were no i n t e r g r o u p d i f f e r e n c e s on t i n n i t u s v a r i a b l e s when da t a were a n a l y s e d a t i n d i v i d u a l phases. To summarize: when the da t a were a n a l y s e d u s i n g m u l t i v a r i a t e s t a t i s t i c s over phases A,B, and C, t h e r e was a s i g n i f i c a n t p e r i o d e f f e c t s i g n i f i c a n t l y a t t r i b u t a b l e t o the l a r g e i n c r e a s e i n t i n n i t u s i n t e n s i t y d u r i n g phase B f o r the a t t e n t i o n f o c u s group which c o n t r a s t e d w i t h the de c r e a s e s a t t h i s time f o r the two comparison groups. S i m i l a r l y , when the s i g n i f i c a n t i n t e r a c t i o n e f f e c t was probed by p e r f o r m i n g r e p e a t e d measures ANOVAs f o r each v a r i a b l e s e p a r a t e l y , t i n n i t u s i n t e n s i t y was the o n l y v a r i a b l e c o n t r i b u t i n g s i g n i f i c a n t l y t o the e f f e c t (see T a b l e 9 ) . b. A n x i e t y 113 The e f f e c t of m a n i p u l a t i n g a n x i e t y on t h e t i n n i t u s v a r i a b l e s d i s t r e s s , i n t e n s i t y , and p i t c h was a s s e s s e d by comparing t h e s e v a r i a b l e s f o r the a n x i e t y group w i t h i t s comparison group (the f a t i g u e group) over phases A,B, and C by measures of a r e p e a t e d measures MANOVA. The MANOVA d i d not r e a c h o v e r a l l s i g n i f i c a n c e f o r the group e f f e c t , F(3,26)=.59, n.s. There was a s i g n i f i c a n t p e r i o d e f f e c t , F(6,23)=2.63, p_<.05. T h i s was f u r t h e r i n v e s t i g a t e d by u n i v a r i a t e a n a l y s e s of i n d i v i d u a l t i n n i t u s v a r i a b l e s . T i n n i t u s i n t e n s i t y and t i n n i t u s p i t c h c o n t r i b u t e d s i g n i f i c a n t l y t o the p e r i o d e f f e c t ( r e s p e c t i v e l y F(1.81,50.64)=3.78, £<.03', and F (1 .68,47.01 )=3.55, p_<«04. The ANOVA f o r t i n n i t u s d i s t r e s s was n o n - s i g n i f i c a n t , F(1.57,44.03)=.53, n.s. P e r i o d x group i n t e r a c t i o n was a l s o n o n - s i g n i f i c a n t , F(6,23)=.95, n.s. These a n a l y s e s a r e summarized i n Ta b l e 10. Subsequent one-way (group) ANOVAs were done a t each phase (A,B, and C) t o probe f o r group d i f f e r e n c e s w i t h the c r i t i c a l s i g n i f i c a n c e l e v e l s e t a t .05/3=.017. None was s i g n i f i c a n t . c. F a t igue A 2 x 6 (group x p e r i o d ) r e p e a t e d measures MANOVA was performed t o compare the e f f e c t s of f a t i g u e on the t i n n i t u s s c o r e s of the f a t i g u e group w i t h those of the c o n t r o l group. None of the group, p e r i o d , or p e r i o d x group i n t e r a c t i o n e f f e c t s was s i g n i f i c a n t ( r e s p e c t i v e l y F(3,26)=.40, n.s.; F(15,14)=1.10, n.s.; F(15,14)=1.21, n.s.; see T a b l e 11). A l t h o u g h the T a b l e 10 Repeated Measures MANOVA w i t h Subsequent ANOVAs on T i n n i t u s V a r i a b l e s f o r A n x i e t y M a n i p u l a t i o n (Comparison Group: F a t i g u e ) T i n n i t u s a. C h A n a l y s i s ( e f f e c t ) Measure MSw df F g MANOVA at A,B,C (group) d, i ,p ANOVA at A, B,C d ANOVA at A, B,C i ANOVA at A, B,C P MANOVA at A,B,C (per i od) d, i , p ANOVA at A, B,C d ANOVA at A, B,C i ANOVA at A, B,C P MANOVA at A (group) d, i ,p ANOVA at A d ANOVA at A i ANOVA at A P MANOVA at B (group) d , i , p ANOVA at B d ANOVA at B i ANOVA at B P MANOVA at C (group) d, i ,p ANOVA at C d ANOVA at C i ANOVA at C P MANOVA at A, B,C ( p e r i o d x group) d, i ,p ANOVA at A, B,C d ANOVA at A, B,C i ANOVA at A, B,C P 3,26 .59 > .62 6 .94 1 , 28 .51 > .48 21 .51 1 ,28 1 .64 > .21 25 .60 1 . 28 1 .86 > . 18 6 , 23 2 .63 < .04 .71 1 .57,44 .03? . 53 > .55 5 . 14 1 .81,50 . 6 4 e 3 . 78 < .04 4 .04 1 .68,47 . 0 1 e 3 .55 < .05 3,26 . 75 > .53 9 .63 1 ,28 1 .96 > . 17 5 .63 1 , 28 1 .03 > .31 2 . 13 1 , 28 .43 > . 52 3,26 .60 > .62 2 .70 1 ,28 .49 > .49 7 . 50 1 , 28 1 . .48 > .23 10. .80 1 , 28 1 . .80 >. . 18 3,26 1 . .83 > . 16 .03 1 , 28 ,01 > .94 8 . 53 1 , 28 1 . .61 >. .21 16 . 13 1 , 28 3. .03 >, .09 6,23 .95 > . 47 2 . 7 1 1 .57,44. 2. .00 >. 15 .07 1 . 81,50. 64 % .06 > . 93 1 . .73 1 .68,47. 0 1 £ 1 . 52 22 Note: a MSb f o r treatments i s r e p r o d u c i b l e from F x MSw b T w o - t a i l e d p r o b a b i l i t y c Using W i l k ' s Lambda c r i t e r i o n d D i s t r e s s , i n t e n s i t y , p i t c h e A f t e r Greenhouse-Geisser adjustment T a b l e 11 Repeated Measures MANOVA w i t h Subsequent ANOVAs on T i n n i t u s V a r i a b l e s f o r F a t i g u e M a n i p u l a t i o n (Comparison Group: C o n t r o l ) T i n n i t u s c A n a l y s i s ( e f f e c t ) Measure MSw df F p_ di MANOVA at A , B, ,C (group) d, i , p 3, 26 .40 > . 75 ANOVA at A, B, ,C d 1 1 .25 1 , 28 . 54 > .47 ANOVA at A, B, ,C i 3 .76 1 , 28 . 20 > .66 ANOVA at A, B, ,C P 5 .00 1 , 28 .24 > .63 MANOVA at A, B, ,C ( p e r i o d ) ) d, i ,p 15, 14 1 . 10 > .43 ANOVA at A , B , C d . 48 3 . 21 , 89 . 8 0 e . 38 > .77 ANOVA at A , B , C i 5 .55 2 .81 , 78. ,69« 4 .44 < .01 ANOVA at A , B, , C P 2 . 64 2 .83, 79 . 2 2 e 1 .70 > . 17 MANOVA at A , B, c ( p e r i o d x group) d, i , p 15, 14 1 .21 > .36 ANOVA at A, B , , c d 2 .42 3 .21 , 89. 8 0 ^ 1 .95 > . 12 ANOVA at A , B, c i 3 . 29 2 81 , 78 . 6 9 e 2 .63 > .05 ANOVA at A. B , c P .84 2 83, 79 . 2 2 e . 54 > .64 Note: a MSb f o r treat m e n t s i s r e p r o d u c i b l e from F x MSw b T w o - t a i l e d p r o b a b i l i t y c U s i n g W i l k ' s Lambda c r i t e r i o n d D i s t r e s s , i n t e n s i t y , p i t c h e A f t e r Greenhouse-Geisser adjustment 116 m u l t i v a r i a t e a n a l y s e s d i d not y i e l d s i g n i f i c a n t r e s u l t s i t was d e c i d e d t o i n v e s t i g a t e the t i n n i t u s v a r i a b l e s i n d i v i d u a l l y t o determine whether t h e r e were any t r e n d s . F i n d i n g s were i n t e r p r e t e d t e n t a t i v e l y . The p e r i o d e f f e c t was s i g n i f i c a n t f o r t i n n i t u s i n t e n s i t y , F(2.81,78.68)=4.44, p_<.00l but not the group e f f e c t nor the p e r i o d x group i n t e r a c t i o n . For t i n n i t u s d i s t r e s s , none of the e f f e c t s was s i g n i f i c a n t , w i t h the i n t e r a c t i o n e f f e c t c l o s e s t t o r e a c h i n g s i g n i f i c a n c e , F(3.21,89.80)=1.95, p>.12. None of the e f f e c t s was s i g n i f i c a n t f o r t i n n i t u s p i t c h . d. T i n n i t u s d i a r y . As a n a t u r a l i s t i c p a r a l l e l t o the l a b o r a t o r y m a n i p u l a t i o n s of t i n n i t u s f o c u s , a n x i e t y , and f a t i g u e , t i n n i t u s d i a r i e s were a n a l y s e d f o r v a r i a t i o n i n t i n n i t u s p i t c h , i n t e n s i t y , and d i s t r e s s by c o n s i d e r i n g the v a l u e s of these v a r i a b l e s f o r the h i g h e s t and lowe s t q u a r t i l e s of the a f f e c t , bored, a n x i o u s , and f a t i g u e d v a r i a b l e s . An extreme groups d e s i g n was s e l e c t e d t o p r o v i d e f o r maximal c o n t r a s t s f o r each a f f e c t v a r i a b l e . The 28 s c o r e s from each s u b j e c t f o r an a f f e c t v a r i a b l e were rank-o r d e r e d . The mean of the seven s c o r e s f o r each t i n n i t u s v a r i a b l e a s s o c i a t e d w i t h the t o p q u a r t i l e , and the mean a s s o c i a t e d w i t h the bottom q u a r t i l e of an a f f e c t v a r i a b l e , were c a l c u l a t e d . The d i f f e r e n c e s of t h e s e means f o r a l l s u b j e c t s , and over the t h r e e t i n n i t u s v a r i a b l e s were t e s t e d i n a one sample t t e s t f o r each a f f e c t v a r i a b l e i n t u r n . S o r t i n g i n t u r n by each a f f e c t v a r i a b l e b o r e d , a n x i o u s , and f a t i g u e d 1 17 r e s p e c t i v e l y , h i g h l y s i g n i f i c a n t d i f f e r e n c e s were o b t a i n e d from T 2 a n a l y s e s of t i n n i t u s p i t c h , i n t e n s i t y , and d i s t r e s s i n each c a s e : F(3,52)=12.06, p_<.0001; F (3,52) = 1 5.04, p_<.000l; F(3,52) = 15.89, p_<.000l. U n i v a r i a t e t - t e s t s were s u b s e q u e n t l y performed on each t i n n i t u s v a r i a b l e and i t was found t h a t f o r e v e r y a f f e c t v a r i a b l e , the v a r i a t i o n i n each t i n n i t u s v a r i a b l e was h i g h l y s i g n i f i c a n t , £<.0001. Hig h v a l u e s of a t i n n i t u s v a r i a b l e were a s s o c i a t e d w i t h h i g h v a l u e s of an a f f e c t v a r i a b l e i n a l l c a s e s . C o r r e l a t i o n s between t i n n i t u s v a r i a b l e s and a f f e c t v a r i a b l e s were a n a l y s e d i n two ways. S t a t i s t i c a l s i g n i f i c a n c e c o u l d not be e s t i m a t e d because of dependencies i n the d a t a a r i s i n g from r e p e a t e d measurement p r o c e d u r e s . F i r s t l y , Pearson c o r r e l a t i o n c o e f f i c i e n t s were c a l c u l a t e d f o r the t h r e e t i n n i t u s v a r i a b l e s and the t h r e e a f f e c t v a r i a b l e s over a l l s u b j e c t s and a l l days (see T a b l e 12). A l l t h e r ' s were p o s i t i v e and v a l u e s v a r i e d from .22 ( t i n n i t u s p i t c h x boredom) t o .70 ( t i n n i t u s d i s t r e s s x t i n n i t u s l o u d n e s s ) . 7 However, i f t h e r e was s u b s t a n t i a l v a r i a b i l i t y i n i n d i v i d u a l c o r r e l a t i o n a l p a t t e r n s (between a f f e c t and t i n n i t u s v a r i a b l e s ) w i t h some p o s i t i v e and o t h e r s n e g a t i v e or c l o s e t o z e r o , i t i s p o s s i b l e t h a t t h e s e g l o b a l c o r r e l a t i o n s might obscure c e r t a i n r e s u l t s . To e x p l o r e f u r t h e r the i n d i v i d u a l i n t e r c o r r e l a t i o n s between t i n n i t u s v a r i a b l e s and a f f e c t v a r i a b l e s on t i n n i t u s 7 A l l s i g n i f i c a n c e s f o r c o r r e l a t i o n s were c a l c u l a t e d f o r two-t a i l e d d i s t r i b u t i o n s . T a b l e 12 ab G l o b a l C o r r e l a t i o n s Between T i n n i t u s V a r i a b l e s and Mood V a r i a b l e s from T i n n i t u s D i a r y . Fat i gue Boredom Anx i e t y T1nn i tus P i t c h T i nni tus Intens i t y T i nn i t u s D i s t r e s s Fat i gue .401 .511 .380 .437 .473 Boredom . 583 . 224 . 398 . 502 Anx i e t y .354 .469 . 628 T i nn i t u s Pi t c h .677 .577 T i nn i t us Intens i t y .696 Note. a ns f o r each c o r r e l a t i o n ranged from 1480 to 1492 b P r o b a b i l i t i e s ( t w o - t a i l e d ) were a l l s i g n i f i c a n t at the .0001 l e v e l 119 d i a r i e s , Pearson c o r r e l a t i o n c o e f f i c i e n t s were c a l c u l a t e d f o r s e l f - r a t i n g s of i n d i v i d u a l s u b j e c t s . No s i g n i f i c a n c e s were c a l c u l a t e d because of the dependencies i n the d a t a due t o the r e p e a t e d measures d e s i g n . T h e i r modal ranges were summarized i n T a b l e 13. Modal c o r r e l a t i o n ranges were p o s i t i v e and low (+.10 t o +.19) between boredom on t h e one hand and t i n n i t u s i n t e n s i t y and p i t c h on the o t h e r . A s i m i l a r modal range was found between p i t c h and a n x i e t y . S l i g h t l y h i g h e r modal ranges (+.20 t o +.29) were found f o r c o r r e l a t i o n s between f a t i g u e on the one hand and t i n n i t u s i n t e n s i t y and p i t c h on the o t h e r , as w e l l as between a n x i e t y and t i n n i t u s d i s t r e s s . The h i g h e s t modal c o r r e l a t i o n s (+.40 t o +.49) were between t i n n i t u s d i s t r e s s and f a t i g u e . The c o r r e l a t i o n s between t i n n i t u s d i s t r e s s and a f f e c t v a r i a b l e s were i n the approximate range +.50 t o +.60. S i n c e the i n t e r c o r r e l a t i o n s between a f f e c t measures were h i g h (about +.40 t o +.60), a c l e a r e r i n d i c a t i o n of c o r r e l a t i o n s between t i n n i t u s d i s t r e s s and each a f f e c t v a r i a b l e would be g i v e n by p a r t i a l l i n g out e f f e c t from the a f f e c t v a r i a b l e under c o n s i d e r a t i o n ( G l a s s & S t a n l e y , 1970). So, f o r example, the p a r t c o r r e l a t i o n between t i n n i t u s d i s t r e s s and a n x i e t y c o u l d be computed w i t h the r e l a t i o n s h i p between a n x i e t y and f a t i g u e removed. I n s p e c t i o n of T a b l e 14 of p a r t c o r r e l a t i o n c o e f f i c i e n t s i n d i c a t e s t h a t p a r t i a l l i n g out a n x i e t y had the l a r g e s t e f f e c t on the c o e f f i c i e n t . The s t r o n g e s t a s s o c i a t i o n s were r and r, (+.45 and +.41 r e s p e c t i v e l y ) . Then f o l l o w e d r 3CB.F) and r. P(+".B) (+.34 and +.30). The p a r t c o r r e l a t i o n s r and r V(B.A) were l o w e s t (+.13 and +.17). a6 T a b l e 13 Modal Ranges of I n t r a i n d i v i d u a l C o r r e l a t i o n s between T i n n i t u s V a r i a b l e s and Mood V a r i a b l e s on T i n n i t u s D i a r i e Mood V a r i a b l e s Fat igue Boredom Anx i e t y T i n n i t u s d i s t r e s s +.40 to +.49 +.20 to +.29 +.20 to +.29 T i n n i t u s i n t e n s i t y +.20 to +.29 + .10 to + . 19 +.20 to +.29 T i n n i t u s p i t c h + . 20 to + . 29 + . 10 to + . 19 + .10 to +. 19 Note: a N = 52 b T i e i n modal range d e c i d e d by median s p l i t 121 Ta b l e 14 P a r t C o r r e l a t i o n C o e f f i c i e n t s Between T i n n i t u s D i s t r e s s and A n x i e t y , F a t i g u e , and Boredom P a r t C o r r e l a t i o n Coef f i c i e n t s "~ V a r i a b l e (v) P P a r t i a l l e d Out D ( A . V ) 'D(F.V) ' D ( B . V ) b none .628 .473 .502 A .177 .167 F .449 .341 B .413 .297 Note, a range of n: 1480-1492 b Pearson r 122 Double-smoothed t i m e - s e r i e s p l o t s (Tukey, 1977) were made of t i n n i t u s d i s t r e s s f o r each s u b j e c t t o i n s p e c t i n d i v i d u a l p a t t e r n s of t h i s v a r i a b l e . Smoothing was performed by c a l c u l a t i n g means s u c c e s s i v e l y of groups of t h r e e d a t a p o i n t s , and then r e p e a t i n g the p r o c e s s on t h e d e r i v e d means. F o r t y - t w o d i a r i e s w i t h no m i s s i n g d a t a were used. Two a s p e c t s of the s e p l o t s were examined: the range of the t i n n i t u s d i s t r e s s r a t i n g (maximum range 1-9), and i t s c y c l i c a l p a t t e r n . Range w i d t h s f o r t i n n i t u s d i s t r e s s v a r i e d from .3 t o 5.3. The modal range was 2 t o 3. There was a h i g h degree of v a r i a b i l i t y of t i n n i t u s d i s t r e s s r a t i n g s w i t h i n s u b j e c t s . Of the 294 d i a r y days r e p o r t e d by 42 s u b j e c t s , o n l y 24 d i a r y days (8%) w i t h c o n s t a n t d i s t r e s s r a t i n g s ( a f t e r d o u b l e smoothing) were r e c o r d e d by as few as n i n e s u b j e c t s . The most common p a t t e r n of d i s t r e s s r a t i n g s over one week ( a f t e r double smoothing) was s i n u s o i d a l w i t h two c y c l e s (50% of s u b j e c t s ) ; f o l l o w e d by 21% w i t h one c y c l e ; and 7% w i t h more than t h r e e . D i s t r e s s r a t i n g s v a r i e d from one t o n i n e c o v e r i n g the f u l l range of the d i a r y d i s t r e s s s c a l e and r e f l e c t i n g a wide range of s u f f e r i n g . The modal range was 2 t o 3 i n d i c a t i n g a p o s i t i v e l y skewed d i s t r i b u t i o n w i t h s u f f e r e r s most f r e q u e n t l y e x p e r i e n c i n g a m i l d degree of d i s t r e s s . The time p a t t e r n i n g of d i s t r e s s r a t i n g s f o r one week i n d i c a t e s a h i g h degree of v a r i a b i l i t y . F a t i g u e s e l f - r a t i n g s on the t i n n i t u s d i a r y were grouped a c c o r d i n g t o whether s u b j e c t s had p r e d i c t e d , p r i o r t o s t a r t i n g 1 23 the d i a r y , whether a p a r t i c u l a r time chosen t o complete the d i a r y would be a l o w - f a t i g u e or a h i g h - f a t i g u e t i m e . A p a i r e d sample t - t e s t on f a t i g u e r a t i n g s showed a s i g n i f i c a n t d i f f e r e n c e between the h i g h - and l o w - f a t i g u e groups of s c o r e s , t(1480)=115.5, 2 < - 0 0 0 1 • e. Other a n a l y s e s . A f o r c e d e n t r y m u l t i p l e r e g r e s s i o n was performed between t i n n i t u s d i s t r e s s as the dependent v a r i a b l e and the independent v a r i a b l e s : c o m p l e x i t y 8 of t i n n i t u s sound, d u r a t i o n ( y e a r s s i n c e onset of t i n n i t u s ) , s u b j e c t i v e p i t c h , s u b j e c t i v e l o u d n e s s , sex, age, and h e a r i n g a b i l i t y (from the H e a r i n g A b i l i t y S c a l e ) . Four of the r e g r e s s i o n c o e f f i c i e n t s d i f f e r e d s i g n i f i c a n t l y from z e r o r e s u l t i n g i n a r e g r e s s i o n e q u a t i o n w i t h s t a n d a r d i z e d r e g r e s s i o n w e i g h t s : T i n n i t u s D i s t r e s s = .56 s u b j e c t i v e i n t e n s i t y - .29 d u r a t i o n + .25 age + .22 c o m p l e x i t y A l t o g e t h e r 61% of v a r i a b i l i t y i n d i s t r e s s c o u l d be p r e d i c t e d from s c o r e s on the s e f o u r v a r i a b l e s . H e a r i n g a b i l i t y , t i n n i t u s p i t c h and sex a l l missed s i g n i f i c a n c e . The r a t i o of b i l a t e r a l : l e f t - s i d e d : r i g h t - s i d e d t i n n i t u s i n t h i s sample (N=60) was 3.9:1.8:1 ( i f the 6 s u b j e c t s who C o m p l e x i t y s c o r e was c a l c u l a t e d by s c o r i n g one f o r each of the s e t i n n i t u s c h a r a c t e r i s t i c s i f p r e s e n t i n an average day: more than one sound, f l u c t u a t e s a l o t between l o u d / s o f t , f l u c t u a t e s a l o t between h i g h / l o w p i t c h , has a d d i t i o n a l sounds s t a r t i n g / s t o p p i n g . 124 d e s c r i b e d the sound as l o c a t e d i n the head r a t h e r than the e a r s a r e i n c l u d e d i n the b i l a t e r a l t o t a l , as per the MRC, 1981 s t u d y ) . The p r e s e n t study t h u s c o n f i r m s the r e l a t i v e l y c o n s i s t e n t f i n d i n g (see T a b l e 1) t h a t l e f t - s i d e d t i n n i t u s i s s u b s t a n t i a l l y more p r e v a l e n t than r i g h t - s i d e d t i n n i t u s . The r a t i o of b i l a t e r a l t o r i g h t - s i d e d t i n n i t u s i n t h i s study i s h i g h e r than any r e p o r t e d i n the l i t e r a t u r e t o d a t e . There a r e i n c o n s i s t e n c i e s i n the r e p o r t i n g of s i d e d n e s s d a t a i n the l i t e r a t u r e . Some a u t h o r s ( e.g. MRC, 1981) s p e c i f y i n c l u s i o n of t i n n i t u s l o c a t e d i n the head i n the b i l a t e r a l c o u n t , w h i l e o t h e r s a r e s i l e n t on t h i s p o i n t (e.g. H a l l a m e t a l , 1984; H a z e l l , 1981b; Reed, 1960). In t h i s s t u d y , i f b i l a t e r a l t i n n i t u s more prominent on one s i d e i s i n c l u d e d i n the count f o r t h a t s i d e (and not i n the b i l a t e r a l c o u n t ) , the p r e v a l e n c e of r i g h t t o l e f t evens out t o y i e l d r a t i o s f o r e q u a l l y - s i d e d : l e f t : r i g h t of 0.7:1.1:1. 125 VI DISCUSSION a. E f f e c t s of a t t e n t i o n f o c u s . The v a r i o u s a n a l y s e s of the a t t e n t i o n f o c u s m a n i p u l a t i o n i n d i c a t e t h a t t h i s m a n i p u l a t i o n was s u c c e s s f u l . The t i n n i t u s f o c u s measure, fo c u s v e r i f i c a t i o n , was the p o t e n t v a r i a b l e a c c o u n t i n g f o r both p e r i o d e f f e c t s and p e r i o d x group e f f e c t s . Measures of a n x i e t y and f a t i g u e d i d not change s i g n i f i c a n t l y d u r i n g t h i s m a n i p u l a t i o n . Focus v e r i f i c a t i o n f o r the a t t e n t i o n f o c u s group rose from the a d a p t a t i o n t o the m a n i p u l a t i o n phases and then dropped i n the r e v e r s a l phase (see F i g u r e s 5,6, & 7 ) . I t was s i g n i f i c a n t l y h i g h e r d u r i n g the m a n i p u l a t i o n phase f o r the a t t e n t i o n f o c u s group than f o r the two comparison groups i n which s u b j e c t s f o c u s e d on number c h e c k i n g or r e a d i n g (the f a t i g u e and c o n t r o l groups, r e s p e c t i v e l y ) . F o c u s s i n g a t t e n t i o n on t i n n i t u s seemed t o a f f e c t the p e r c e i v e d t i n n i t u s i n t e n s i t y . When a t t e n t i o n a l f o c u s was d i r e c t e d t o the t i n n i t u s sound, t i n n i t u s i n t e n s i t y i n c r e a s e d and when a t t e n t i o n was d i r e c t e d away, t i n n i t u s i n t e n s i t y d e c r e a s e d . Changes i n t i n n i t u s i n t e n s i t y s i g n i f i c a n t l y accounted f o r both the p e r i o d e f f e c t and the p e r i o d x time i n t e r a c t i o n e f f e c t i n t h i s s t u d y . There i s a s u g g e s t i o n t h a t t i n n i t u s p i t c h might be a f f e c t e d by a t t e n t i o n f o c u s , but t h i s e f f e c t was not s t a t i s t i c a l l y s u p p o r t e d . These f i n d i n g s p a r a l l e l d a t a from the l i t e r a t u r e where i t has been found t h a t f o c u s s i n g on symptoms i n c r e a s e s p e r c e i v e d 126 non-pain symptom i n t e n s i t y (Pennebaker & L i g h t n e r , 1980; where a m p l i f i e d sounds of t h e i r own b r e a t h i n g were p l a y e d t o j o g g e r s ) . D i r e c t i n g a t t e n t i o n of s u b j e c t s t o t h e i r p a i n i n a c o l d - p r e s s o r t a s k d e c r e a s e d t o l e r a n c e t o p a i n and i n c r e a s e d the s e l f - r a t e d d i s c o m f o r t i n the p a i n - f o c u s s i n g group compared w i t h the d i s t r a c t i o n groups (K a n f e r & G o l d f o o t , 1966). T h i s s u g gests an i m p o r t a n t d i s t i n c t i o n between t i n n i t u s and p a i n . W h i l e sound i s not i n t r i n s i c a l l y d i s t r e s s i n g , p a i n i s . C r a i g (1984) has s u g g e s t e d t h a t d i s a g r e e a b l e e m o t i o n a l components may be a n e c e s s a r y a t t r i b u t e f o r e x p e r i e n c e s t o be r e a s o n a b l y d e s c r i b e d as p a i n . Thus i t c o u l d be t h a t w i t h o u t t h e s e components, f o c u s s i n g on t i n n i t u s d i d not r e s u l t i n i n c r e a s e d d i s t r e s s . D u r i n g the m a n i p u l a t i o n phase (when a t t e n t i o n f o c u s s u b j e c t s were f o c u s s i n g on t h e i r t i n n i t u s ) , the comparison group members were engaging i n t a s k s ( c h e c k i n g numbers or r e a d i n g ) t h a t can be r e g a r d e d as r e l a t i v e l y d i s t r a c t i n g from t h e i r t i n n i t u s when compared t o the a d a p t a t i o n phase ( i n which some of the a c t i v i t y i n v o l v e d a n s w e r i n g q u e s t i o n n a i r e s about t i n n i t u s ) . Both comparison groups show d e c r e a s e s i n t i n n i t u s i n t e n s i t y and p i t c h , p r o b a b l y due t o the d i s t r a c t i n g e f f e c t s of t h e i r d u t i e s (see F i g u r e s 5,6, & 7 ) . T i n n i t u s d i s t r e s s d e c l i n e d from the a d a p t a t i o n phase t o the m a n i p u l a t i o n ( r e a d i n g ) phase f o r c o n t r o l s u b j e c t s but d i d not change f o r number v i g i l a n c e t a s k ( f a t i g u e ) s u b j e c t s between the s e phases. T h i s may be due t o the more d i s t r a c t i n g e f f e c t s of r e a d i n g p o s s i b l y because i t may have been more e n g r o s s i n g . D i s t r a c t i o n has been found t o reduce the number of symptoms n o t i c e d and the p e r c e i v e d l e v e l of f a t i g u e 127 f o r j o g g e r s (Pennebaker & L i g h t n e r , 1980). McCaul & M a l o t t (1984) r e v i e w e d the l i t e r a t u r e on the e f f e c t s of d i s t r a c t i o n on p a i n and c o n c l u d e d t h a t most e x p e r i m e n t a l s t u d i e s found t h a t d i s t r a c t i o n was a s s o c i a t e d w i t h h i g h e r p a i n t h r e s h o l d s and i n c r e a s e d t o l e r a n c e ( e.g. McCaul & Haugtvedt, 1982). R y b s t e i n -B l i n c h i k (1979) found t h a t the use of n e u t r a l imagery caused r e d u c t i o n s i n s e l f - r a t i n g s of p a i n i n t e n s i t y i n c h r o n i c p a i n p a t i e n t s . The commencement of the d i s t r a c t i n g t a s k i n phase C was a s s o c i a t e d w i t h a sharp d e c l i n e i n t i n n i t u s i n t e n s i t y f o r the a t t e n t i o n f o c u s s u b j e c t s (see F i g 6 ) . A p o s s i b l e framework f o r e x p l a i n i n g t h i s i s the c o n t r o l l e d and a u t o m a t i c i n f o r m a t i o n p r o c e s s i n g model proposed by S c h n e i d e r & S h i f f r i n (1977). What i s termed c o n t r o l l e d p r o c e s s i n g i n v o l v e s the c o n s c i o u s a l l o c a t i o n of s h o r t - t e r m memory s t o r e t o a t a s k . I t i s c a p a c i t y - b o u n d i n t h a t , when a t a s k i s more d i f f i c u l t or a b s o r b i n g , i t becomes more d i f f i c u l t t o a t t e n d t o an u n r e l a t e d t a s k . P r o c e s s i n g of t a s k s which r e q u i r e m i n i m a l a t t e n t i o n or awareness i s termed a u t o m a t i c p r o c e s s i n g . McCaul & M a l o t t (1984) propose t h a t a t t e n t i o n both t o symptoms (e.g. t i n n i t u s or p a i n ) and a t t e n t i o n t o d i s t r a c t o r s ( i n t h i s c a s e , the number v i g i l a n c e and the r e a d i n g t a s k s ) r e q u i r e c o n t r o l l e d p r o c e s s i n g . S i n c e c a p a c i t y f o r t h i s t ype of p r o c e s s i n g i s supposedly l i m i t e d , expending i t on d i s t r a c t o r s would, a c c o r d i n g t o t h i s model, d e c r e a s e the a v a i l a b l e c a p a c i t y f o r a t t e n t i o n t o symptoms ( i n t h i s c a s e , t i n n i t u s ) . In support of t h i s model, f o c u s v e r i f i c a t i o n r a t i n g s dropped s h a r p l y f o r both d i s t r a c t i o n groups 128 ( f a t i g u e and c o n t r o l ) and r o s e s u b s t a n t i a l l y f o r the t i n n i t u s f o c u s group from the a d a p t a t i o n phase t o the m a n i p u l a t i o n phase (see F i g . 3 ) , w i t h t i n n i t u s i n t e n s i t y r a t i n g s r e f l e c t i n g t h i s . When the t i n n i t u s f o c u s m a n i p u l a t i o n was r e v e r s e d , t i n n i t u s i n t e n s i t y dropped c o r r e s p o n d i n g l y . In the r e v e r s a l phase C of t h i s m a n i p u l a t i o n , a t t e n t i o n f o c u s s u b j e c t s were r e q u e s t e d t o s t o p f o c u s s i n g on t i n n i t u s and i n s t e a d t o t h i n k about a p r o x i m a t e , n e u t r a l , everyday a c t i v i t y such as p l a n n i n g the d i n n e r menu, or the d e t a i l s of the r o u t e t o be f o l l o w e d when g o i n g home. Comparison s u b j e c t s c o n t i n u e d d u r i n g t h i s phase C w i t h t a s k s s t a r t e d i n phase B. W h i l e t h e r e was a sharp d e c r e a s e i n t i n n i t u s i n t e n s i t y f o r a t t e n t i o n focus s u b j e c t s , between phases B and C, i n t e n s i t y c o n t i n u e d t o f a l l f o r c o n t r o l ( r e a d i n g ) s u b j e c t s , and remained the same f o r the f a t i g u e (number v i g i l a n c e ) s u b j e c t s . T i n n i t u s p i t c h was l e s s a f f e c t e d by the t i n n i t u s f o c u s / d i s t r a c t i o n m a n i p u l a t i o n a l t h o u g h t h e r e i s a t r e n d s u g g e s t i v e of concordance w i t h i n t e n s i t y . I n t e r e s t i n g l y , when s u b j e c t s were asked ( i n open-ended q u e s t i o n s ) , p r i o r t o p a r t i c i p a t i o n i n the r e s e a r c h , t o d e s c r i b e w hich s i t u a t i o n s improved or d e c r e a s e d t o l e r a n c e t o t i n n i t u s , of those who i n c l u d e d d i s t r a c t i n g s i t u a t i o n s i n t h e i r r e p l i e s , 45% of responses d e s c r i b e d t h a t b e i n g i n v o l v e d i n some o t h e r a c t i v i t y i n g e n e r a l was a s s o c i a t e d w i t h t i n n i t u s b e i n g l e s s t r o u b l e s o m e . No s u b j e c t s responded t h a t d i s t r a c t i o n made t i n n i t u s worse. C o n v e r s e l y 4.4% of responses i n d i c a t e d t h a t f o c u s s i n g on t i n n i t u s seemed t o make i t worse and none found t h a t t h i s improved t o l e r a n c e t o i t . Thus i t appears t h a t 129 s u b j e c t s were more l i k e l y t o a t t r i b u t e b e n e f i t s i n e x p e r i e n c i n g t i n n i t u s t o d i s t r a c t i o n , than t o a t t r i b u t e e x a c e r b a t i n g e f f e c t s t o f o c u s s i n g on the t i n n i t u s . b. E f f e c t s of a n x i e t y . The s t a t i s t i c a l e v a l u a t i o n of the a n x i e t y m a n i p u l a t i o n i n d i c a t e d t h a t , as measured by the s e l f - r e p o r t v a r i a b l e s chosen, the m a n i p u l a t i o n was u n s u c c e s s f u l a l t h o u g h h e a r t r a t e responded to the m a n i p u l a t i o n w i t h a s i g n i f i c a n t i n c r e a s e d u r i n g the m a n i p u l a t i o n phase (see f i g . 4 ) . I t i s i n t e r e s t i n g t o note t h a t when d e b r i e f i n g s u b j e c t s a f t e r a n x i e t y i n d u c t i o n , many sp o n t a n e o u s l y o f f e r e d s t r o n g d e n i a l s t h a t the m a n i p u l a t i o n was a n x i e t y - p r o v o k i n g . One c o u l d s p e c u l a t e t h a t they f e l t c o n s t r a i n e d i n a d m i t t i n g t o f e e l i n g a n x i o u s and t h a t t h i s i s r e f l e c t e d i n t h e i r s e l f - r a t i n g s but not i n t h e i r h e a r t r a t e . In a l a b o r a t o r y s t u d y i n v e s t i g a t i n g whether the presence of o b s e r v e r s a f f e c t e d r e s p o n s e s of s u b j e c t s t o p a i n f u l e l e c t r i c shock, K l e c k e t a l . (1976) found t h a t b e i n g o b s e r v e d had an a t t e n u a t i n g e f f e c t on n o n - v e r b a l e x p r e s s i o n of p a i n , s u b j e c t i v e p a i n r a t i n g s , and s k i n conductance. I z a r d (1971) has suggested t h a t s o c i a l i z a t i o n p l a y s an i m p o r t a n t p a r t i n i n h i b i t i n g or a t t e n u a t i n g e x p r e s s i v e b e h a v i o u r t o p a i n i n the presence of o t h e r s . He argued t h a t t h i s might be because p a r e n t s might i n c r e a s i n g l y p u n i s h d i s p l a y s of emotion by c h i l d r e n as they age from i n f a n c y through c h i l d h o o d . I n d u c t i o n of a n x i e t y by u s i n g an o b s e r v i n g a u d i e n c e w i t h 130 v i d e o t a p i n g has been a c h i e v e d i n a t l e a s t one o t h e r study (Craske & C r a i g , 1984). S u b j e c t s were p i a n i s t s , h a l f of whom were c l a s s i f i e d as r e l a t i v e l y a n x i o u s and h a l f as r e l a t i v e l y nonanxious p e r f o r m e r s . The presence of an audie n c e e l i c i t e d e l e v a t i o n s i n s e l f - r e p o r t e d d i s t r e s s l e v e l s o n l y f o r the r e l a t i v e l y a n x i o u s group, but caused i n c r e a s e d h e a r t r a t e f o r bot h c l a s s i f i c a t i o n s . These s t u d i e s i n d i c a t e d t h a t the presence of o b s e r v e r s can evoke a more complex response than the e l e v a t i o n of a n x i e t y e x p e c t e d from the m a n i p u l a t i o n i n t h i s r e s e a r c h . The t i n n i t e u r s were not p r e s e l e c t e d t o form a "performance a n x i e t y " group and t h i s might e x p l a i n why they d i d not respond w i t h i n c r e a s e d a n x i e t y t o b e i n g o b s e r v e d . I t may a l s o be t h a t the reason o f f e r e d by the e x p e r i m e n t e r f o r the o b s e r v a t i o n was not as c r e d i b l e as when p r o v i d e d t o s u b j e c t s who were p i a n i s t s f o r whom p e r f o r m i n g f o r an audie n c e i s more congruent w i t h the e x p e r i m e n t a l c o n t e x t (as i n Craske & C r a i g , 1984). The f a i l u r e t o ge n e r a t e a h i g h l e v e l of a n x i e t y i s r e f l e c t e d i n the absence of s i g n i f i c a n t group, and p e r i o d x group i n t e r a c t i o n e f f e c t s f o r the t i n n i t u s v a r i a b l e s . The s i g n i f i c a n t p e r i o d e f f e c t i s accounted f o r by changes i n t i n n i t u s i n t e n s i t y and p i t c h (but not d i s t r e s s ) . I t r e f l e c t s the r e s p o n s i v e n e s s of t i n n i t u s i n t e n s i t y and p i t c h t o an e x p e r i m e n t a l t a s k which was e s s e n t i a l l y d i s t r a c t i n g (see F i g u r e s 5, 6, and 7 ) . The d i f f e r i n g response between h e a r t r a t e and r e p o r t e d 131 a n x i e t y may be e x p l a i n e d i n terms of the " t h r e e systems model" of a n x i e t y (Lang, 1981) which d e s c r i b e s t h r e e l o o s e l y - c o u p l e d components: b e h a v i o u r a l , p h y s i o l o g i c a l , and v e r b a l . These components a r e c a p a b l e of r e s p o n d i n g d i f f e r e n t i a l l y a t a g i v e n time i . e . they a re d i s c o r d a n t . Thus Rachman (1978) r e p o r t s t h a t s e l f - r e p o r t s of f e a r tend t o c o r r e l a t e q u i t e w e l l w i t h a v o i d a n c e b e h a v i o u r , but l e s s c l o s e l y w i t h autonomic i n d i c a t o r s of f e a r . Hodgson and Rachman (1974) extended t h i s model by i n t r o d u c i n g p r e d i c t i o n s about the degree of c o v a r i a t i o n over time among the t h r e e systems. Rachman (1978) suggested t h a t the tempora l o r d e r of change was u s u a l l y f i r s t autonomic, then b e h a v i o u r a l , and f i n a l l y v e r b a l . Thus i t i s p o s s i b l e t h a t , whereas HR i n c r e a s e d i n the m a n i p u l a t i o n phase B f o r the a n x i e t y group (see F i g u r e 4 ) , changes i n a n x i e t y as r e f l e c t e d i n s e l f -r e p o r t measures had not y e t de v e l o p e d because of the b r e v i t y of the a n x i e t y i n d u c t i o n . Hodgson & Rachman (1974) h y p o t h e s i z e d t h a t concordance would be more l i k e l y under c o n d i t i o n s e v o k i n g s t r o n g e m o t i o n a l r e s p o n s e s . S i n c e the a n x i e t y m a n i p u l a t i o n was d e s i g n e d t o evoke a m i l d r e s u l t , t h i s c o u l d e x p l a i n the d i f f e r e n c e i n responses between the two systems. In c o n t r a s t t o the s e l f - r e p o r t measures of a n x i e t y , HR shows both a s i g n i f i c a n t p e r i o d e f f e c t and p e r i o d x group i n t e r a c t i o n . The q u a d r a t i c components of the s e e f f e c t s a r e even more pronounced. I t ap p e a r s , t h e r e f o r e , t h a t whereas s e l f - r e p o r t measures of a n x i e t y were not a f f e c t e d by the m a n i p u l a t i o n , HR changed s i g n i f i c a n t l y . As d i s c u s s e d above, t h e r e a re d i f f i c u l t i e s i n d e c i d i n g whether t i n n i t e u r s s u b j e c t e d t o t h i s m a n i p u l a t i o n became more a n x i o u s 132 d u r i n g m a n i p u l a t i o n phase B. . T h e i r r a t i n g s of t i n n i t u s v a r i a b l e s showed d e c r e a s e s from a d a p t a t i o n phase t o m a n i p u l a t i o n phase, whereas i t was h y p o t h e s i z e d t h a t a n x i e t y would causes i n c r e a s e s . One e x p l a n a t i o n i s t h a t , r a t h e r than b e i n g an a n x i e t y - p r o v o k i n g t a s k , number v i g i l a n c e w i t h o b s e r v a t i o n s e r v e d as a d i s t r a c t i n g t a s k . T h i s might have m i t i g a t e d a g a i n s t the e x p e c t e d l y a g g r a v a t i n g e f f e c t s of a n x i e t y on t i n n i t u s . A l t h o u g h t h i s confound was c o n s i d e r e d when d e s i g n i n g the r e s e a r c h by h a v i n g a c o n t r o l group perf o r m the same t a s k w i t h o u t a n x i e t y i n d u c t i o n , i t might be argued t h a t the p a r t i c u l a r a n x i e t y i n d u c t i o n used might have had the e f f e c t of c a u s i n g c l o s e r a t t e n t i o n t o the number v i g i l a n c e t a s k w i t h r e s u l t i n g i n c r e a s e d d i s t r a c t i o n from t i n n i t u s . However, t h i s p o s s i b i l i t y i s not s u p p o r t e d by the f o c u s v e r i f i c a t i o n measurements. Both the a n x i e t y and the comparison groups r e a c t e d v e r y s i m i l a r l y on t h i s measure (see F i g u r e 3 ) . I t i s i n t e r e s t i n g t o note t h a t on t h e t i n n i t u s survey q u e s t i o n n a i r e 51.7% of the s u b j e c t s l i s t e d a n x i e t y as a a f f e c t which i n c r e a s e d the degree t o which t i n n i t u s b o t h e r e d them. Only 1.7% (one s u b j e c t ) f e l t t h a t b e i n g a n x i o u s improved t i n n i t u s . I t appears t h a t many t i n n i t e u r s a r e aware t h a t i n c r e a s e d a n x i e t y i s a s s o c i a t e d w i t h e x a c e r b a t i o n of t i n n i t u s symptoms. R a t i n g s of a n x i e t y from the T i n n i t u s D i a r y were found t o c o r r e l a t e s i g n i f i c a n t l y and p o s i t i v e l y w i t h r a t i n g s of a l l t h r e e t i n n i t u s v a r i a b l e s : p i t c h , i n t e n s i t y , d i s t r e s s (r=.35, .47 and 1 33 .63 r e s p e c t i v e l y ) from the T i n n i t u s D i a r y over a l l s u b j e c t s . When i n t r a i n d i v i d u a l c o r r e l a t i o n s f o r these v a r i a b l e s were computed, a wide range of c o r r e l a t i o n became apparent w i t h about 30% of s u b j e c t s h a v i n g r ' s of z e r o or l e s s . I t i s c l e a r t h a t the t i n n i t u s v a r i a b l e s of some s u f f e r e r s i s a s s o c i a t e d h i g h l y and p o s i t i v e l y w i t h a n x i e t y (r=.4 t o .8 f o r the upper q u a r t i l e ) . For o t h e r s they a r e a s s o c i a t e d n e g a t i v e l y or not a t a l l w i t h a n x i e t y (r=.0 t o - . 5 ) . P a r t c o r r e l a t i o n s between t i n n i t u s d i s t r e s s and s e l f -r a t i n g s of a n x i e t y , f a t i g u e , or boredom i n d i c a t e d t h a t the a s s o c i a t i o n between t i n n i t u s d i s t r e s s and a n x i e t y was s t r o n g e s t i n comparison w i t h i t s a s s o c i a t i o n s w i t h f a t i g u e or boredom. c. E f f e c t s of f a t i g u e . R e s u l t s show t h a t s e l f - r e p o r t measures of f a t i g u e i n c r e a s e d s i g n i f i c a n t l y over time d u r i n g the e x p e r i m e n t a l t a s k . There were no s i g n i f i c a n t group d i f f e r e n c e s nor p e r i o d x group i n t e r a c t i o n e f f e c t s on t h i s v a r i a b l e . T h i s s u g g e s t s t h a t both the f a t i g u i n g and the c o n t r o l t a s k s l e d t o i n c r e a s e s i n t h i s measure and t h a t s u b j e c t s i n b oth groups r a t e d f a t i g u e s i m i l a r l y . None of the t i n n i t u s v a r i a b l e s was s i g n i f i c a n t l y a f f e c t e d by t h e f a t i g u i n g m a n i p u l a t i o n when e f f e c t s were c o n s i d e r e d i n a m u l t i v a r i a t e c o n t e x t . There i s a s u g g e s t i o n of t i n n i t u s i n t e n s i t y i n c r e a s i n g w i t h i n c r e a s i n g f a t i g u e which was not s u p p o r t e d s t a t i s t i c a l l y , but f a t i g u e seemed t o have had no 134 e f f e c t on t i n n i t u s d i s t r e s s and t i n n i t u s p i t c h (see F i g u r e s 5, 6, &7). I t may be im p o r t a n t t o note i n d e s i g n i n g treatment programs f o r t i n n i t u s d i s t r e s s t h a t t h e r e were no d i f f e r e n t i a l e f f e c t s on t i n n i t u s v a r i a b l e s whether t i n n i t e u r s engaged i n a more l e i s u r e l y d i s t r a c t i o n ( r e a d i n g ) or i n a more demanding t a s k (number v i g i l a n c e ) . I t i s a l s o noteworthy t h a t , from phase B of d o i n g the r e q u i r e d t a s k , b oth the r e a d i n g and the number v i g i l a n c e s u b j e c t s ( i n the c o n t r o l and f a t i g u e groups) had almost e q u i v a l e n t v a l u e s f o r f o c u s v e r i f i c a t i o n d u r i n g the remainder of the m a n i p u l a t i o n . A t a s k d e s i g n e d t o have a h i g h degree of a t t e n t i o n a l demand does not d e t r a c t from f o c u s on t i n n i t u s any more than a t a s k w i t h p u r p o r t e d l y l e s s a t t e n t i o n a l demand. HR d a t a r e f l e c t a s i g n i f i c a n t o v e r a l l d e c r ease i n HR over time w i t h HR s i g n i f i c a n t l y h i g h e r f o r the f a t i g u e group than f o r the c o n t r o l group throughout the m a n i p u l a t i o n . The reason f o r t h i s d i f f e r e n t i a l e f f e c t may be due t o the d i f f e r e n c e s i n p h y s i c a l a c t i v i t y between the two groups w i t h the number v i g i l a n c e s u b j e c t s b e i n g more a c t i v e and the r e a d i n g s u b j e c t s more s e d e n t a r y . I f t h i s were so, the s i g n i f i c a n t HR d i f f e r e n c e s f o r p e r i o d and p e r i o d x group i n t e r a c t i o n may r e f l e c t more of an a c t i v i t y l e v e l confound than o t h e r c o g n i t i v e l y - b a s e d e f f e c t s . B e r l y n e ( i 9 6 0 ) has suggested t h a t boredom i n c r e a s e s autonomic a r o u s a l . T h i s has been s u p p o r t e d e x p e r i m e n t a l l y (e.g. London, S c h u b e r t , and Washburn, 1972 who m o n i t o r e d HR). They o f f e r the 1 35 e x p l a n a t i o n t h a t i f a t a s k i s b o r i n g because i t i s too e a s y , " c o n t i n u e d a t t e n t i o n r e q u i r e s . . . autonomic a r o u s a l " . An a l t e r n a t i v e e x p l a n a t i o n i s t h a t HR was h i g h e r f o r the f a t i g u e group because they were more bored by t h e i r t a s k compared w i t h t h e r e a d i n g group. R a t i n g s of f a t i g u e from the T i n n i t u s D i a r y were found t o c o r r e l a t e s i g n i f i c a n t l y and p o s i t i v e l y w i t h r a t i n g s of a l l t h r e e t i n n i t u s v a r i a b l e s : p i t c h , i n t e n s i t y , and d i s t r e s s (r=.38, .44, and .47 r e s p e c t i v e l y ) from the T i n n i t u s D i a r y over a l l s u b j e c t s . When i n t r a i n d i v i d u a l c o r r e l a t i o n s f o r these v a r i a b l e s were computed, a wide range of c o r r e l a t i o n became apparent as was the case when a n x i e t y was c o n s i d e r e d . About 30% of s u b j e c t s had r ' s of z e r o or l e s s . I t i s c l e a r t h a t r a t i n g s of f a t i g u e a r e c o r r e l a t e d h i g h l y and p o s i t i v e l y w i t h the t i n n i t u s v a r i a b l e s f o r some t i n n i t e u r s (r=.4 t o .8 f o r the upper q u a r t i l e ) . For o t h e r s , they a r e a s s o c i a t e d n e g a t i v e l y or not a t a l l (r=.0 t o -.7) . The q u e s t i o n a r i s e s why two such d i f f e r e n t a f f e c t s t a t e s might a f f e c t t i n n i t u s v a r i a b l e s s i m i l a r l y . A p o s s i b l e e x p l a n a t i o n emerges from R u s s e l l ' s c i r c u m p l e x model of a f f e c t ( R u s s e l l , 1980). Because t h e s e two a f f e c t s t a t e s have the a t t r i b u t e of u n p l e a s a n t n e s s i n common, i t may be t h i s a s pect of n e g a t i v e a f f e c t t h a t i s a s s o c i a t e d w i t h e x a c e r b a t i o n of symptoms ( c f . Romano and T u r n e r , 1985). The o t h e r dimension of a r o u s a l / u n a r o u s a l which R u s s e l l ' s t w o - d i m e n s i o n a l model of a f f e c t p r o p o s e s , does not account f o r the s i m i l a r e f f e c t t h a t 136 a n x i e t y and f a t i g u e have on t i n n i t u s v a r i a b l e s because t h e s e |MUDLs have q u i t e d i f f e r e n t a r o u s a l l e v e l s i n the model. Emotions which are r a t e d as more p l e a s a n t seem t o c o r r e s p o n d t o l e s s d i s t r e s s and lower r a t i n g s of p i t c h and i n t e n s i t y . U n p l easant emotions a r e a s s o c i a t e d w i t h h i g h e r l e v e l s of t h e s e v a r i a b l e s . A s u b s t a n t i a l number of s u b j e c t s (37%) r e p o r t e d t h a t , i n t h e i r n a t u r a l environment, f a t i g u e was a s s o c i a t e d w i t h e x a c e r b a t i o n of t i n n i t u s . When s u b j e c t s were asked i n open-ended q u e s t i o n s on the T i n n i t u s Q u e s t i o n n a i r e , p r i o r t o p a r t i c i p a t i n g i n the r e s e a r c h , t o d e s c r i b e which f a c t o r s were a s s o c i a t e d w i t h t i n n i t u s b o t h e r i n g them more, two c l a s s e s of responses were s u p p l i e d by s u b j e c t s . One c l a s s ( d i s t r a c t i o n / a t t e n t i o n ) has been d e s c r i b e d above. Summarized b r i e f l y , 40% responded t h a t d i s t r a c t i n g a c t i v i t y a m e l i o r a t e d t i n n i t u s , and none responded t h a t i t was e x a c e r b a t e d by such a c t i v i t y . The second c l a s s of responses r e f e r r e d t o e n v i r o n m e n t a l sound l e v e l s and the s e responses were more i d i o s y n c r a t i c than the f i r s t c l a s s . Q u i e t n e s s was a s s o c i a t e d w i t h e x a c e r b a t i o n of t i n n i t u s f o r some s u b j e c t s (32.3% of r e s p o n s e s ) , but o t h e r s u b j e c t s a s s o c i a t e d i t w i t h a s s i s t i n g i n t o l e r a n c e of t i n n i t u s ( 1 4 . 1 % ) . S i m i l a r l y , n o i s e was a s s o c i a t e d w i t h e x a c e r b a t i o n of t i n n i t u s (30.9%) b u t , f o r o t h e r s u b j e c t s , w i t h an improved t o l e r a n c e ( 8 . 5 % ) . In c o n t r a s t , "background sounds" was not l i s t e d as an e x a c e r b a t i n g f a c t o r by any s u b j e c t , where 19.7% of responses i n d i c a t e d t h a t background sounds h e l p e d t o l e r a n c e of t i n n i t u s . Thus the most f r e q u e n t l y s uggested a m e l i o r a t i n g f a c t o r was d i s t r a c t i o n and second most 137 f r e q u e n t was background sounds. S u b j e c t s were i d i o s y n c r a t i c i n e x p r e s s i n g t h e i r responses t o q u i e t n e s s and t o n o i s e : f o r some t h e s e were a m e l i o r a t i n g f a c t o r s and f o r o t h e r s , e x a c e r b a t i n g . d. Summary of f i n d i n g s . The a t t e n t i o n a l f o c u s m a n i p u l a t i o n was s u c c e s s f u l and p r i m a r i l y a f f e c t e d t i n n i t u s i n t e n s i t y . When f o c u s was d i r e c t e d towards the t i n n i t u s , i t s i n t e n s i t y i n c r e a s e d , and when f o c u s was d i r e c t e d away from the t i n n i t u s , i t s i n t e n s i t y d e c r e a s e d . E x p e r i m e n t a l r e s u l t s thus c o n f i r m h y p o t h e s i s 1 i n s o f a r as t i n n i t u s i n t e n s i t y i s concerned, not f o r t i n n i t u s d i s t r e s s . S i m i l a r l y d i s t r a c t i o n was found t o be a s s o c i a t e d w i t h a d e c r e a s e i n t i n n i t u s i n t e n s i t y but not i n t i n n i t u s d i s t r e s s . The a n x i e t y m a n i p u l a t i o n d i d not l e a d t o a s i g n i f i c a n t i n c r e a s e i n s e l f - r e p o r t e d a n x i e t y ( a l t h o u g h h e a r t - r a t e was s i g n i f i c a n t l y i n c r e a s e d d u r i n g the a n x i e t y m a n i p u l a t i o n ) . T h i s e x p e r i m e n t a l m a n i p u l a t i o n d i d not cause changes i n the t i n n i t u s v a r i a b l e s , d i s t r e s s , i n t e n s i t y , and p i t c h . The t h i r d h y p o t h e s i s c o u l d not be a d e q u a t e l y t e s t e d because of the f a i l u r e t o induce h i g h enough a n x i e t y l e v e l s i n s u b j e c t s . N a t u r a l i s t i c r e p o r t i n g s u p p o r t e d the f o u r t h h y p o t h e s i s and y i e l d e d a s t r o n g p o s i t i v e a s s o c i a t i o n between a n x i e t y and t i n n i t u s d i s t r e s s . The e x p e r i m e n t a l m a n i p u l a t i o n of f a t i g u e l e d t o s i g n i f i c a n t i n c r e a s e s i n s e l f - r e p o r t e d f a t i g u e i n b o t h the f a t i g u e and c o n t r o l group members but d i d not b r i n g about s i g n i f i c a n t changes i n the t i n n i t u s v a r i a b l e s . H y p o t h e s i s 5 was t h e r e f o r e 1 38 not s u p p o r t e d by the l a b o r a t o r y m a n i p u l a t i o n of f a t i g u e . However, the n a t u r a l i s t i c p a r a l l e l of t h i s found s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s between f a t i g u e and t i n n i t u s d i s t r e s s , i n t e n s i t y and p i t c h and s u p p o r t e d h y p o t h e s i s 6. e. A proposed model of t i n n i t u s d i s t r e s s . The r e s u l t s of t h i s r e s e a r c h t o g e t h e r w i t h i n f o r m a t i o n from the t i n n i t u s l i t e r a t u r e i n d i c a t e the f o l l o w i n g model t o d e s c r i b e f a c t o r s which are l i k e l y t o i n f l u e n c e the l e v e l of d i s t r e s s f e l t from t i n n i t u s and i t s e t i o l o g y . 1. P r e d i s p o s i n g f a c t o r s . P r e d i s p o s i n g f a c t o r s (Evans, 1981) a r e g e n e r a l f a c t o r s whose presence i s a s s o c i a t e d w i t h an i n c r e a s e d p r o b a b i l i t y of t i n n i t u s o c c u r r i n g but whose absence does not p r e c l u d e the p o s s i b i l i t y of t i n n i t u s . Examples a r e p resence of m u l t i p l e s c l e r o s i s , h y p e r t h y r o i d i s m , and d i a b e t e s ( S c h l e u n i n g , 1981). 2. C a u s a t o r y f a c t o r s . These a r e f a c t o r s which a r e u n e q u i v o c a l l y a s s o c i a t e d w i t h onset of t i n n i t u s (McFadden, 1982). They i n c l u d e d i s e a s e p r o c e s s e s , p h y s i c a l damage t o the ear or head, and o t o t o x i c s u b s t a n c e s . For the m a j o r i t y of c a s e s , however, the c a u s a t o r y f a c t o r s are not s p e c i f i a b l e . 3. R e v e a l i n g f a c t o r s . I t i s p o s s i b l e f o r an ear-sound t o be p r e s e n t but not d e f i n e d by the h e a r e r as a symptom. In t h i s case a r e v e a l i n g f a c t o r (Evans, 1981) may b r i n g a sound t h a t the p a t i e n t was unaware of t o awareness. 4. M o d u l a t i n g f a c t o r s . Whereas p r e d i s p o s i n g , c a u s a t o r y , and r e v e a l i n g f a c t o r s are a l l concerned w i t h the presence or absence 139 of t i n n i t u s or the awareness of i t s p r e s e n c e , m o d u l a t i n g f a c t o r s i n f l u e n c e the l e v e l of d i s t r e s s f e l t from t i n n i t u s : ( i ) T h i s r e s e a r c h i n d i c a t e s t h a t the demographic f a c t o r , h i g h e r age, i s s i g n i f i c a n t l y a s s o c i a t e d w i t h i n c r e a s e d d i s t r e s s . ( i i ) T i n n i t u s c h a r a c t e r i s t i c s such as h i g h e r p e r c e i v e d t i n n i t u s i n t e n s i t y , i n c r e a s e d t i n n i t u s c o m p l e x i t y , and s h o r t d u r a t i o n s i n c e t i n n i t u s o n s e t , have l i k e w i s e been found i n t h i s r e s e a r c h t o be l i n k e d w i t h h i g h e r d i s t r e s s l e v e l s . ( i i i ) N e g a t i v e a f f e c t s t a t e s such as f a t i g u e or a n x i e t y which have u n p l e a s a n t n e s s of a f f e c t as an a t t r i b u t e ( r a t h e r than h i g h or low a r o u s a l ) have been found t o be e x a c e r b a t i n g t i n n i t u s d i s t r e s s i n t h i s r e s e a r c h . C o n v e r s e l y , p o s i t i v e a f f e c t s t a t e s w i t h p l e a s a n t n e s s of a f f e c t as an a t t r i b u t e , tended t o a m e l i o r a t e d i s t r e s s . ( i v ) E n v i r o n m e n t a l sound l e v e l s seem t o be a f a c t o r . S u b j e c t s i n d i c a t e d t h a t l o u d e n v i r o n m e n t a l sounds tended t o be e x a c e r b a t i n g , and the presence of background sounds a m e l i o r a t i n g of d i s t r e s s . A q u i e t environment seems t o a f f e c t t i n n i t u s d i s t r e s s more i d i o s y n c r a t i c a l l y . Some t i n n i t e u r s a s s o c i a t e i t w i t h i n c r e a s e d d i s t r e s s and o t h e r w i t h d e c r e a s e d d i s t r e s s . (v) C o g n i t i v e f a c t o r s seem t o p l a y a r o l e i n m o d u l a t i n g d i s t r e s s . One such f a c t o r i s a t t e n t i o n a l f o c u s . T h i s r e s e a r c h has found t h a t when a t t e n t i o n was f o c u s e d on the t i n n i t u s sound, i t s p e r c e i v e d i n t e n s i t y i n c r e a s e d ; and i t was a l s o d e t e r m i n e d t h a t h i g h e r i n t e n s i t y l e v e l s were a s s o c i a t e d w i t h i n c r e a s e d d i s t r e s s . C o n v e r s e l y , d i s t r a c t i o n was r e l a t e d t o d e c r e a s e d i n t e n s i t y l e v e l s and d i s t r e s s . A second c o g n i t i v e f a c t o r (observed i n c l i n i c a l work but not e x p e r i m e n t a l l y i n v e s t i g a t e d ) may w e l l be 1 40 the n a t u r e of the b e l i e f system r e g a r d i n g t i n n i t u s h e l d by a t i n n i t e u r . N e g a t i v e b e l i e f s such as "my t i n n i t u s w i l l get l o u d e r u n t i l I w i l l not be a b l e t o hear a n y t h i n g " or " my t i n n i t u s i n d i c a t e s t h a t I have something s e r i o u s l y wrong w i t h my b r a i n " a r e v e r y l i k e l y t o be a s s o c i a t e d w i t h h i g h e r d i s t r e s s l e v e l s . An i m p o r t a n t d i f f e r e n c e between t h i s proposed model and the h a b i t u a t i o n model of t o l e r a n c e f o r t i n n i t u s (Hallam, Rachman, & H i n c h c l i f f e , 1984) i s the v a r y i n g emphasis on a r o u s a l as a component. The h a b i t u a t i o n model proposes t h a t a r o u s a l l e v e l i s an i m p o r t a n t v a r i a b l e w i t h r e s p e c t t o the h a b i t u a t i o n p r o c e s s : low a r o u s a l f a c i l i t a t i n g h a b i t u a t i o n and h i g h a r o u s a l r e t a r d i n g h a b i t u a t i o n . The p r e s e n t study found some e v i d e n c e t h a t the p l e a s a n t n e s s d i m e n s i o n of a f f e c t ( r a t h e r than the a r o u s a l d imension) was i m p o r t a n t i n a f f e c t i n g t i n n i t u s . The e f f e c t s of a r o u s a l on t i n n i t u s need t o be i n v e s t i g a t e d more c l o s e l y b e f o r e more c o n f i d e n t s t a t e m e n t s can be made about t h i s r e l a t i o n s h i p . The model proposed i n t h i s s tudy s t r e s s e s the importance of c o g n i t i v e f a c t o r s on the c o u r s e of t i n n i t u s d i s t r e s s . I t proposes t h a t r e v e a l i n g f a c t o r s a r e a n e c e s s a r y element f o r the development of t i n n i t u s d i s t r e s s . For some p e o p l e w i t h ear sounds i t i s c o n c e i v a b l e t h a t they would not be re g a r d e d as symptoms i . e . they do not a c q u i r e a n e g a t i v e s i g n i f i c a n c e . The h a b i t u a t i o n model does not make t h i s d i s t i n c t i o n . The model proposed i n t h i s study s u g g e s t s t h a t the b e l i e f system h e l d by t i n n i t e u r s about t i n n i t u s , may s i g n i f i c a n t l y 141 a f f e c t the c o u r s e of t h e i r d i s t r e s s . I n f o r m a t i o n s u p p l i e d t o t i n n i t e u r s t o c o r r e c t i n a c c u r a t e n e g a t i v e b e l i e f s may f a c i l i t a t e h a b i t u a t i o n . A l t h o u g h the h a b i t u a t i o n model a l l u d e s t o the e f f e c t s of b e l i e f s and r e v e a l i n g f a c t o r s , i t r e g a r d s them as secondary f a c t o r s . The p r e s e n t model r e g a r d s them as p r i m a r y . The two models have a number of components i n common: the d e c r e a s e i n t i n n i t u s d i s t r e s s as d u r a t i o n of t i n n i t u s i n c r e a s e s ; the v a r i a b i l i t y of t i n n i t u s sounds as a f a c t o r (the p r e s e n t model p r o p o s i n g more s p e c i f i c a l l y what the elements of t i n n i t u s c o m p l e x i t y a r e ) ; and the r o l e t h a t e n v i r o n m e n t a l sound p l a y s . f . I m p l i c a t i o n s f o r measurement. F i n d i n g s from t h i s r e s e a r c h have i m p l i c a t i o n s f o r what measurement i s r e l e v a n t f o r r e s e a r c h i n t i n n i t u s d i s t r e s s . S u b j e c t i v e r a t i n g of h e a r i n g a b i l i t y does not seem t o be a s i g n i f i c a n t f a c t o r . Stephens & Hallam (1985) have s i m i l a r l y found t h a t degree of h e a r i n g d i f f i c u l t y bore no r e l a t i o n s h i p t o measures of p s y c h o p a t h o l o g y on the Crown C r i s p E x p e r i e n t i a l Index. P r e v i o u s r e s e a r c h has r e p e a t e d l y demonstrated t h a t o b j e c t i v e l y measured t i n n i t u s l o u d n e s s was u n c o r r e l a t e d w i t h t i n n i t u s d i s t r e s s . Here i t has been found t h a t the s u b j e c t i v e i n t e n s i t y of the t i n n i t u s sound i s a s i g n i f i c a n t f a c t o r i n d e t e r m i n i n g t i n n i t u s d i s t r e s s . I t would be c o n v e n i e n t f o r t i n n i t u s r e s e a r c h e r s t o measure t h i s i n t e n s i t y on a u n i f o r m s c a l e and i t i s suggested t h a t a v i s u a l analogue s c a l e of the t y p e used here would be a p p r o p r i a t e . R e c e n t l y Jakes et a l . 142 (1986) found t h a t s c o r e s on Guttman-type s c a l e s and a d j e c t i v a l s c a l e s produced good c o r r e l a t i o n s w i t h l o u d n e s s match v a l u e s . C o m p l e x i t y of the t i n n i t u s sound has not p r e v i o u s l y been r e p o r t e d as a t i n n i t u s measure i n the l i t e r a t u r e . The zero/one w e i g h t i n g system f o r absence/presence of each of the f o u r components of t i n n i t u s c o m p l e x i t y was u t i l i z e d i n t h i s r e s e a r c h . The components were: m u l t i p l i c i t y of sounds, s u b s t a n t i a l i n t e n s i t y f l u c t u a t i o n , s u b s t a n t i a l p i t c h f l u c t u a t i o n , and a p p e a r a n c e / d i s a p p e a r a n c e of a d d i t i o n a l sounds ( a l l w i t h i n an "average" d a y ) . T h i s c o m p l e x i t y measure p r o v e d t o be s i g n i f i c a n t l y c o r r e l a t e d w i t h t i n n i t u s d i s t r e s s . I t i s t h e r e f o r e recommended t h a t a measure of c o m p l e x i t y be c o n s i d e r e d f o r a p p r o p r i a t e n e s s of i n c l u s i o n i n f u t u r e r e s e a r c h . Where a f f e c t i s a r e l e v a n t v a r i a b l e i n t i n n i t u s r e s e a r c h , t h e r e i s some e v i d e n c e t h a t measurement of a f f e c t s h o u l d be made of both the a r o u s a l and p l e a s a n t n e s s dimensions as c o n c e i v e d i n R u s s e l l ' s t w o - d i m e n s i o n a l model of a f f e c t (1980). T h i s r e s e a r c h found t h a t the p l e a s a n t n e s s of a f f e c t ( r a t h e r than a r o u s a l ) was the d i m e n s i o n more c l o s e l y a s s o c i a t e d w i t h t i n n i t u s d i s t r e s s . The i m p l i c a t i o n i s t h a t something might be m i s s e d i f , f o r example, i n c o n s i d e r i n g the e f f e c t s of r e l a x a t i o n t r a i n i n g on t i n n i t u s d i s t r e s s , o n l y a r o u s a l were measured (as i s u s u a l l y the c a s e ) . 143 g. I m p l i c a t i o n s f o r t r e a t m e n t . Sweetow (1984) has d e s c r i b e d a c o g n i t i v e b e h a v i o u r a l t r e a t m e n t approach f o r t i n n i t u s d i s t r e s s modeled a f t e r Turk, Meichenbaum, and Genest (1983). Data from t h i s p r e s e n t r e s e a r c h i n d i c a t e the importance of a t t e n t i o n a l f o c u s as a f a c t o r i n i n c r e a s i n g or d e c r e a s i n g t i n n i t u s d i s t r e s s . I t would seem t h a t f o r more a c u t e l y d i s t r e s s i n g s i t u a t i o n s , s p e c i f i c t e c h n i q u e s of d i s t r a c t i o n would be h e l p f u l . Long d u r a t i o n s l e e p l a t e n c y has been improved c l i n i c a l l y by i m a g i n a t i v e t r a n s f o r m a t i o n of the t i n n i t u s sound ( c f . Turk et a l . , 1983); f o r example from the h i s s i n g i t was heard a s , t o the sound of a i r i s s u i n g from the a i r n o z z l e i n an a i r p l a n e t o H a w a i i . For some t i n n i t e u r s c o m p l e t i n g c r o s s w o r d p u z z l e s has been d e s c r i b e d by them as b e i n g so a b s o r b i n g as t o r e s u l t i n the absence of awareness of the t i n n i t u s sound. The d r a m a t i c e f f e c t of the a t t e n t i o n / d i s t r a c t i o n s w i t c h can be r e a d i l y r e c a l l e d by most t i n n i t e u r s . The l o n g - t e r m b e n e f i c i a l e f f e c t s of the l o n g e r d u r a t i o n d i s t r a c t o r s such as work, h o b b i e s , and s o c i a l i nvolvement a r e a l s o t o be c a r e f u l l y c o n s i d e r e d and encouraged i n t r e a t m e n t . The p r e s e n t r e s e a r c h has demonstrated the e x a c e r b a t i n g e f f e c t t h a t a n x i e t y has on t i n n i t u s d i s t r e s s . H a l l a m & Stephens (1985) found t h a t t i n n i t e u r s have a h i g h e r a n x i e t y s c o r e on the Crown C r i s p E x p e r i e n t i a l Index than the g e n e r a l p o p u l a t i o n . T h i s i m p l i e s t h a t a l l e v i a t i o n of a n x i e t y l e v e l s would have b e n e f i c i a l r e s u l t s on t i n n i t u s d i s t r e s s . The b e n e f i t s of 1 44 r e l a x a t i o n t r a i n i n g f o r d i s t r e s s from t i n n i t u s have been documented i n an e x p e r i m e n t a l - d e s i g n study by S c o t t , L i n d b e r g , L y t t k e n s , and M e l i n (1985). T h e i r s t u d y , however, combined r e l a x a t i o n t r a i n i n g and d i s t r a c t i o n t r a i n i n g and d i d not attempt a d i s m a n t l i n g a n a l y s i s of the s e two components. H a l l a m & Jakes (1985) have r e p o r t e d a case study i n which r e l a x a t i o n t r a i n i n g d e c r e a s e d t i n n i t u s annoyance but not s u b j e c t i v e l o u d n e s s . I n t e r e s t i n g l y the a n t i - a n x i e t y d r u g , V a l i u m , has not been g e n e r a l l y found t o h e l p t i n n i t e u r s (Goodey, 1981). I f t h i s i m p l i e s t h a t i t i s not the change i n the a r o u s a l dimension t h a t i s r e l e v a n t but r a t h e r the change i n the p l e a s a n t n e s s d i m e n s i o n , then t h i s would be i n l i n e w i t h p r e s e n t f i n d i n g s . I t f o l l o w s t h a t h e u r i s t i c a l l y , i t might be i n f o r m a t i v e t o t e s t the e f f e c t s of a n t i - d e p r e s s a n t m e d i c a t i o n s on t i n n i t u s d i s t r e s s i f i n f a c t t h e s e work by changing the p l e a s a n t n e s s d i m e n s i o n of a f f e c t . A n a l y s i s of the e f f e c t s of a n t i - d e p r e s s a n t s on the components of a f f e c t have not been r e p o r t e d i n the l i t e r a t u r e t o d a t e . The i n d i v i d u a l i t y of responses t o t i n n i t u s has been e v i d e n t from a n a l y s i s of t i n n i t u s d i a r i e s . The t i n n i t u s c y c l e s of some t i n n i t e u r s showed wide i n t e r s u b j e c t v a r i a b i l i t y i n the range of t i n n i t u s d i s t r e s s r a t i n g s . Some showed v e r y l i t t l e f l u c t u a t i o n and o t h e r s broad f l u c t u a t i o n of t i n n i t u s d i s t r e s s . The c y c l i c i t y of d i s t r e s s a l s o v a r i e d : h a l f of the s u b j e c t s had two c y c l e s of t i n n i t u s d i s t r e s s w i t h i n a week but o t h e r s had one c y c l e or more than two. From a tr e a t m e n t p e r s p e c t i v e , i t would be h e l p f u l t o be a b l e t o . s p e c i f y the f a c t o r ( s ) f o r an i n d i v i d u a l t i n n i t e u r t h a t i s a s s o c i a t e d w i t h t h i s f l u c t u a t i o n . I f t h i s 1 45 c o u l d be r e g u l a t e d , the t i n n i t u s d i s t r e s s . w o u l d be a b l e t o be b e t t e r c o n t r o l l e d . The i n d i v i d u a l i t y of t i n n i t u s p a t t e r n s over time s u g g e s t s the c l i n i c a l importance of t i n n i t e u r s k e e p i n g t i n n i t u s d i a r i e s p r e - t r e a t m e n t f o r a t l e a s t a week f o r an o t h e r r e a s o n . T h i s c o u l d p r o v i d e n e c e s s a r y i n f o r m a t i o n p o s t - t r e a t m e n t f o r a s s e s s i n g t r e a t m e n t e f f i c a c y . A v oidance of f a t i g u e s h o u l d be an i m p o r t a n t element i n a treatment program. S u b j e c t s i n t h i s s tudy s e l f - m o n i t o r e d f a t i g u e f o r a week. A s i g n i f i c a n t c o r r e l a t i o n was found between f a t i g u e and t i n n i t u s d i s t r e s s . T h i s i n d i c a t e s t h a t an improvement i n p h y s i c a l f i t n e s s , and more s l e e p i n c a s e s of s l e e p d i s t u r b a n c e (which i s a common co n c o m i t a n t of t i n n i t u s ) would g e n e r a l l y improve d i s t r e s s from t i n n i t u s . The proposed model of t i n n i t u s d i s t r e s s s u g g ests t h a t an impo r t a n t component of a tr e a t m e n t program would be i n f o r m a t i o n a l . There would be an emphasis on c h a n g i n g i n a c c u r a t e b e l i e f s about the e f f e c t s of t i n n i t u s and i t s c o u r s e . Hallam & J a k e s (1985) have noted the importance of i n f o r m a t i o n a l a s p e c t s of t r e a t m e n t i n a case study r e p o r t . h. F u t u r e r e s e a r c h . T h i s s t u d y was c o n c e i v e d as a p r e c u r s o r t o a p s y c h o l o g i c a l t r e a t m e n t program f o r t i n n i t u s d i s t r e s s . A l t h o u g h a t e n t a t i v e framework f o r such a program e x i s t s , more b a s i c r e s e a r c h i s n e c e s s a r y t o d e c i d e which program elements a r e e f f i c a c i o u s and t o r e f i n e methods of u s i n g t h e s e elements c l i n i c a l l y . 146 The absence of r e p o r t e d r e s e a r c h r e g a r d i n g the r e l a t i o n s h i p between b e l i e f systems of t i n n i t e u r s about t h e i r symptoms and d i s t r e s s i s a s i g n i f i c a n t gap i n knowledge of p s y c h o l o g i c a l a s p e c t s of t i n n i t u s . There i s ongoing r e s e a r c h i n s u r g i c a l , d r u g , and p h y s i c a l t r e a t m e n t m o d a l i t i e s f o r t i n n i t u s . P a i n t r e a t m e n t has the advantage of h a v i n g e f f e c t i v e a n a l g e s i c s a v a i l a b l e f o r many p a t i e n t s whereas no such m e d i c a t i o n e x i s t s f o r t i n n i t u s . Both symptoms, however, share the problem of l a r g e numbers of d i s t r e s s e d s u f f e r e r s who have no immediate p r o s p e c t of s a t i s f a c t o r y a l e v i a t i o n . I t seems t h a t f o r t i n n i t u s , p s y c h o l o g i c a l t r e a t m e n t which aims a t d e c r e a s i n g d i s t r e s s r a t h e r than e r a s i n g the symptom s h o u l d be an i m p o r t a n t emphasis i n r e s e a r c h u n t i l s a f e and e f f e c t i v e methods of s i l e n c i n g t i n n i t u s a r e d i s c o v e r e d . 147 V I I REFERENCES A h l e s , T.A., B l a n c h a r d , E.B., & L e v e n t h a l , H. (1983). C o g n i t i v e c o n t r o l of p a i n : a t t e n t i o n t o the se n s o r y a s p e c t s of the c o l d p r e s s o r s t i m u l u s . C o g n i t i v e Therapy & r e s e a r c h , 7, 159-178. Aran, J . , & C a z a l s , Y. (1981). E l e c t r i c a l s u p p r e s s i o n of t i n n i t u s . 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T i n n i t u s r e s e a r c h f r o n t i e r s . H e a r i n g  I n s t r u m e n t s , 930, 3-33. Voroba, G. (1979b). T i n n i t u s masking n o i s e : fundamental measures & a c a u t i o n a r y n o t e . H e a r i n g A i d J o u r n a l , 32., 8. Walsh, W.M. , & G e r l e y , P.P. (1985). Thermal b i o f e e d b a c k & the tr e a t m e n t of t i n n i t u s . Laryngoscope, 95, 987-989. Ward, N.G., Bloom, V.L., and F r i e d e l , R.O. (1979). The e f f e c t i v e n e s s of t r i c y c l i c a n t i - d e p r e s s a n t s i n the t r e a t m e n t of c o e x i s t i n g p a i n and d e p r e s s i o n . P a i n , 1_, 331. Warren, N., & C l a r k , B. (1937). B l o c k i n g i n mental & motor t a s k s d u r i n g a 65-hour v i g i l . J o u r n a l of E x p e r i m e n t a l  P s y c h o l o g y , 21, 97-105. Weisenberg, M. (1977). P a i n & p a i n c o n t r o l . P s y c h o l o g i c a l  B u l l e t i n , 84, 1008-1044. W i l s o n , J.P. (1979). R e c o r d i n g of the Kemp echo & t i n n i t u s from the ear c a n a l w i t h o u t a v e r a g i n g . P r o c e e d i n g s of the  P h y s i o l o g i c a l S o c i e t y , 298, 8-9. W i l s o n , J.P. (1980). E v i d e n c e f o r a c o c h l e a r o r i g i n f o r a c o u s t i c r e - e m i s s i o n s , t h r e s h o l d f i n e - s t r u c t u r e , & t o n a l t i n n i t u s . H e a r i n g R e s e a r c h , 2, 233-252. W i l s o n , J.P., & S u t t o n , G.J. (1981). A c o u s t i c c o r r e l a t e s of t o n a l t i n n i t u s . In T i n n i t u s (CIBA F o u n d a t i o n Symposium85). London: Pitman. Winer, B.J. (1962). S t a t i s t i c a l p r i n c i p l e s i n e x p e r i m e n t a l  d e s i g n . New York: M c G r a w - H i l l . Wolf, S.L., & Rao, V. (1983). Transcutaneous e l e c t r i c a l 159 s t i m u l a t i o n : use and misuse. In J.F. Brena & S.L. Chapman ( E d s . ) , Management of p a t i e n t s w i t h c h r o n i c p a i n . New York: Spectrum P u b l i c a t i o n s . Zurek, P.M. P e r s o n a l communication c i t e d i n McFadden, 1982, p201 . Zurek, P.M. (1981). Spontaneous narrowband a c o u s t i c s i g n a l s e m i t t e d by human e a r s . J o u r n a l of the A c o u s t i c a l S o c i e t y  of A m e r i c a , 69, 514-523. 1 60 Appendix A A p i l o t study was run t o examine how f a t i g u e might be induced e x p e r i m e n t a l l y so as t o r e s u l t i n i n c r e a s e s i n s e l f -r e p o r t e d f a t i g u e i n s u b j e c t s . I f s u c c e s s f u l , the method c o u l d be used t o induce f a t i g u e i n t i n n i t e u r s i n o r d e r t o a s s e s s i t s e f f e c t s e x p e r i m e n t a l l y . C o l l e g e undergraduates (who d i d not s u f f e r from t i n n i t u s ) were randomly a s s i g n e d t o an e x p e r i m e n t a l (22 s u b j e c t s ) or a c o n t r o l group (21 s u b j e c t s ) . E x p e r i m e n t a l s u b j e c t s scanned rows of numbers c o n t i n u o u s l y f o r 60 m i n u t e s . They were r e q u i r e d t o mark o f f the t a r g e t number s p e c i f i e d f o r each row. Measurements were ta k e n b e f o r e , midway, and a t the end of the s e s s i o n by a d m i n i s t e r i n g the R u s s e l l A f f e c t S c a l e . C o n t r o l s u b j e c t s read N a t i o n a l Geographic Magazines f o r 60 minutes and were s i m i l a r l y measured. The p i l o t study found t h a t : 1. the i n c r e a s e i n s e l f - r e p o r t e d f a t i g u e i n the f a t i g u e group was s i g n i f i c a n t l y h i g h e r than t h a t o b s e r v e d i n the c o n t r o l group of s u b j e c t s . A r e p e a t e d measures ANCOVA ( w i t h i n i t i a l s c o r e s as t h e c o v a r i a t e ) on f a t i g u e as r e p o r t e d on a v i s u a l analogue s c a l e found a s i g n i f i c a n t group e f f e c t , F(1,40)=4.84, 2<•0 4. 2. l e v e l of c o n c e n t r a t i o n (as s e l f - r e p o r t e d on a v i s u a l analogue s c a l e ) on the e x p e r i m e n t a l t a s k was s i g n i f i c a n t l y n e g a t i v e l y c o r r e l a t e d w i t h l e v e l of f a t i g u e , r=-.53, p_<.01. 161 Appendi x B S c r e e n i n g Form S u b j e c t number Name Phone (home) (work) F o r c o m p l e t i o n by e x o e r i m e n t e r . PLEASE CHECK WHERE APPROPRIATE. A. T i nn i t u s / h e a r i nq; 1. I n t e r n a l sound or -sounds p r e s e n t i n e a r s or head o c c u r r i n g i n t h e a b s e n c e of e x t e r n a l a c o u s t i c s t i m u l i 2. The s o u n d ( s ) a r e n o t v o l u n t a r i l y r e p r o d u c i b l e 3. The sound (s) a r e h e a r d c o n t i n u o u s l y 4. The s o u n d ( s ) a r e n o t r e s p o n s i v e t o m e d i c a l t r e a t m e n t 5. D u r a t i o n o-f t i n n i t u s / / y e a r s OR / /months The sound (s) have been h e a r d -for a t l e a s t t h r e e months 6. Does t h e s u b j e c t wear a h e a r i n c i a i d ? no / _/ some o-f t h e t i me / _ / most of t h e t i me / a l 1 of t h e t i me / / 7. Can t h e s u b j e c t u n d e r s t a n d normal l e v e l s of s p e e c h i n a q u i e t room w i t h o u t a h e a r i n g a i d ? no/ / y e s / / B. P e r s o n a l d a t a : 8. Age ....(make a checkmark i f 18 t o 75 y e a r s ) 9. H i g h e s t g r a d e p a s s e d a t s c h o o l ? 10. I s t h e s u b j e c t c u r r e n t l y r e c e i v i n g t r e a t m e n t f o r a s e r i o u s p s y c h o l o g i c a l d i s o r d e r ? y e s / / no/' / If " y e s " , p l e a s e s u p p l y d e t a i l s ( n a t u r e of p r o b l e m , d u r a t i o n o f c u r r e n t t h e r a p y , e t c . ) SEE OVER 11. I s t h e s u b j e c t w i l l i n g t o p a r t i c i p a t e i n t h i s r e s e a r c h by s p e n d i n g a b o u t 1 1/2 h o u r s w i t h u s ? 162 A p p e n d i ;c . n n i t u s D i a r y Sub ,ect no. S e q u e n c a .TO. DATE • 1985 DAY. TIME am/pm WAS YOUR TINNITUS PRESENT AT THE ABOVE TIME? Ives o r no) AT THE TIME WRITTEN ABOVE o l e a s e make an "X" somewhere a l o n g t h e l i n e t o i n d i c a t e how you a r e f e e l i n g now and how vour t i n n i t u s i s . P l e a s e do not w r i t e your mark ON t h e d o t s . W r i t e i t i n one o-f t h e s p a c e s . EXAMRLE X T i n n i t u s p i t c h T i n n i t u s o i t c h n o t a t a l l h i g h : : : : : : ; '. e x t r e m e l y h i g h T i n n i t u s T i n n i t u s n o t a t a l l e x t r e m e l y l o u d : : : : : : : : l o u d T i n n i t u s n o t a t a l l T i n n i t u s e x t r e m e l v d i s t r e s s i n g : : : : : : : : d i s t r e s s i n g P L EASE CONTINUE OVERLEAF 163 Not at a l l -fatigued : : _: : : : : : Extremely -fatigued Extremely bored Not at a l l bored Not at a l l anxious Extremely anxious NOW PLEASE DETACH THIS FORM AND PLACE IT IN THE ENVELOPE PROVIDED. THANK YOU 164 A p p e n d i x D R u s s e l l A f f e c t S c a l e S u b j e c t number S e q u e n c e Some o f t h e word p a i r s b e l o w may seem u n u s u a l , b u t y o u ' l l p r o b a b l y f e e l more one way t h a n a n o t h e r . 3o, f o r e a c h word p a i r below, p u t a c h e c k m a r k somewhere a l o n g t h e l i n e t o i n d i c a t e how you a r e f e e l i n g now. P l e a s e do NOT w r i t e your mark on t h e DOTS. W r i t e i t i n one of t h e SPACES. EXAMPLE When you h a ve f i n i s h e d , p l e a s e be s u r e t h a t t h e r e i s one c h e c k on e a c h l i n e . Unhappy R e l axed PI e a s e d Not a t a l l f a t i g u e d E x c i t e d Di s s a t i s f i ed T i n n i t u s e x t r e m e l y d i s t r e s s i n g Happy S t i m u l a t e d Annoved E x t r e m e l y f a t i g u e d C a l m S a t i s f i e d T i n n i t u s n o t a t a l l d i s t r e s s i ng S l u g g i s h : : : : : : : : •_ F r e n z i e d U n a b l e t o c o n c e n t r a t e : : : : : : s : A b l e t o c o n c e n t r a t e C o n t e n t e d : : : : : : : : M e l a n c h o l i c T i nn i t u s p i t c h n o t a t a l l h i g h J i t t e r y D e s p a i r i n g E x t r e m e l y a n g r y S I e e p y T i nn i t u s ex t r e m e l y 1oud R e l a x ed A r o u s e d Not a t a l l a n x i o u s T i n n i t u s p i t c h e x t r e m e l y h i g h Dul 1 H o p e f u l Not a t a l 1 a n g r y Wide awake T i n n i t u s n o t a t a l l 1 oud 3or ed U n a r o u s e d E x t r e m e l y a n x i o u s Appendi;: E F o c u s Ver i f i c a t i on ( T i n n i t u s V e r s i o n ) Bub i e c t number S e q u e n c e What p e r c e n t a g e of t i m e , f r o m when I a s k e d you t o b e g i n f o c u s s i n g on v o u r t i n n i t u s , would you e s t i m a t e t h a t you s p e n t THINKING ABOUT YOUR TINNITUS? P l e a s e make an X somewhere a l o n g t h e l i n e below t o i n d i c a t e t h i s . Example: ;_X_>" PERCENTAGE : s : : : .* : s : s 0'/. 10/1 20/1 3 OX 40/1 50"/. 60"/. 70"/. 80"/. 90/1 1007. OF TIME Appendix F F o c u s V e r i f i c a t i o n (Number V e r s i o n ) S u b j e c t number S e q u e n c e What p e r c e n t a g e of t i m e , f r o m when I a s k e d you t o b e g i n m a r k i n g o f f numbers, would you e s t i m a t e t h a t you s p e n t THINKING ABOUT YOUR TINNITUS? P l e a s e make an X somewhere a l o n g t h e l i n e below t o i n d i c a t e t h i s . E xample: ; X : PERCENTAGE ; J : : : : : : '• = 07. 107. 20V. Z07. 407. 507. &07. 707. 307. 907. 100% •F TIME A p p e n d i x G F o c u s V e r i f i c a t i o n ( R e a d i n g V e r s i o n ) Sub i e c t number S e q u e n c e What p e r c e n t a g e of t i m e , f r o m when I a s k e d y o u t o b e g i n r e a d i n g t h e m a g a z i n e s , would you e s t i m a t e t h a t you s p e n t THINKING ABOUT YOUR TINNITUS? P l e a s e make an X somewhere a l o n g t h e l i n e below t o i n d i c a t e t h i s . E xample: :_X_: PERCENTAGE : i : s : : : : : : 0'/. 10/1 20% 30"/. 40% 50% 60% 70% 80% 9 0 % 100% OF TIME 168 Appendix H HEARING ABILITY SCALE S u b j e c t number. P l e a s e answer t h e - f o l l o w i n g q u e s t i o n s t h e way you u s u a l 1 y hear w i t h both e a r s . I-f you a r e u s i n g a h e a r i n g a i d , p l e a s e answer t h e way you hear wi t h o u t a h e a r i n g a i d . FOR EACH QUESTION CHECK EITHER YES OR NO. Y E S 1. Can you u s u a l l y hear and u n d e r s t a n d what a o e r s o n s a y s w i t h o u t s e e i n g h i s or her -face i-f he or she w h i s p e r s t o you -from a c r o s s a q u i e t room? 2. Can you u s u a l l y hear and u n d e r s t a n d what a p e r s o n s a y s w i t h o u t s e e i n g h i s or her f a c e i f he or she t a l k s i n a normal v o i c e t o you -from a c r o s s a q u i e t room? 3 . Can you u s u a l l y hear and u n d e r s t a n d what a p e r s o n s a y s w i t h o u t s e e i n g h i s or her -face i-f he or she s h o u t s t o you from a c r o s s a q u i e t room? 4. Can vou u s u a l l y hear and u n d e r s t a n d a p e r s o n i f he or she speaks l o u d l y i n t o your b e t t e r e a r ? 5. Can you u s u a l l y t e l l t h e sound of speech from o t h e r sounds and n o i s e s ? 6. Can vou u s u a l l y t e l l one k i n d of n o i s e -from a n o t h e r ' Can vou hear l o u d n o i s e s ? 169 Appendix I T i n n i t u s Q u e s t i o n n a i r e S u b j e c t number... T i n n i t u s i s t h e sound or sounds t h a t you hear i n your e a r ( s ) o r head even when t h e r e i s no sound b e i n g made n e a r you. PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR TINNITUS. 1. I have had t i n n i t u s f o r y e a r s months 2. My t i n n i t u s b o t h e r s me MORE when I am f e e l i n g 3. My t i n n i t u s b o t h e r s me LESS when I am f e e l i n g 4. My t i n n i t u s b o t h e r s me MORE when I am i n t h e f o l l o w i n g p l a c e s or s i t u a t i o n s 5. My t i n n i t u s b o t h e r s me LESS when I am i n t h e f o l l o w i n g p l a c e s or s i t u a t i o n s Do you USUALLY h e a r more t h a n one t i n n i t u s s o u n d ? (YES or NO) If you do h e a r more t h a n one sound, p l e a s e answer t h e f o l l o w i n g q u e s t i o n s about t h e MAIN sound you h e a r . I f you 170 T i n n i t u s Q u e s t i o n n a i r e ( c o n t ) h e a r o n l y ONE sound, p l e a s e answer t h e f o l l o w i n g q u e s t i o n s a b o u t i t . 6. P l e a s e make a mark on t h e f o l l o w i n g v e r t i c a l l i n e a t p o i n t which you f e e l d e s c r i b e s how HIGH-PITCHED or how LOW-PITCHED your t i n n i t u s sound u s u a l l y i s : e x t r e m e l y h i g h - p i t c h e d ex t r e m e l y 1ow-pi t c h e d 7. The c l o s e s t d e s c r i p t i o n t h a t I can g i v e of t h e main t i n n i t u s sound i s t h a t i t so u n d s l i k e T i n n i t u s Q u e s t i o n n a i r e ( c o n t ) 8. P l e a s e make a mark on t h e - f o l l o w i n g v e r t i c a l l i n e a t p o i n t w hich you -feel d e s c r i b e s how LOUD o r how SOFT your t i n n i t u s sound u s u a l l y i s : e x t r e m e l y 1 oud ex t r e m e l y s o f t 172 T i n n i t u s Q u e s t i o n n a i r e ( c o n t ) 9. P l e a s e make a mark on t h e f o l l o w i n g v e r t i c a l l i n e a t a p o i n t w hich you f e e l d e s c r i b e s how DISTRESSING y o u r t i n n i t u s sound g e n e r a l l y i s : e x t r e m e l y d i t r e s s i ng n o t a t a l l d i s t r e s s i ng 173 T i n n i t u s Q u e s t i o n n a i r e ( c o n t ) 10. My MAIN t i n n i t u s sound seems t o be l o c a t e d : (CHECK ONE) i n my l e f t e ar / / i n my r i g h t e a r / / i n b o t h e a r s but m a i n l y i n my l e f t e a r / / i n b o t h e a r s but m a i n l y i n my r i g h t e a r / / i n b o t h e a r s e q u a l l y / / i n mv head / / 11. IN AN AVERAGE DAY my t i n n i t u s sound (or s o u n d s ) CHECK WHICHEVER DESCRIPTIONS APPLY TO YOU: s t a y s f a i r l y c o n s t a n t / / f l u c t u a t e s a l o t between l o u d and s o f t / / f l u c t u a t e s a l o t between h i g h - p i t c h e d and l o w - p i t c h e d / / has a d d i t i o n a l s o u n d s s t a r t i n g and s t o p p i n g / / 12. From what you know about y o u r s e l f , g i v e TWO t i m e s IN AN AVERAGE DAY when you u s u a l l y f e e l LESS FATIGUED t h a n a t o t h e r t i m e s : 1....am/pm 2....am/pm Now p l e a s e g i v e two t i m e s when you u s u a l l y f e e l M0F;E FATIGUED t h a n a t o t h e r t i m e s : 1....am/pm 2....am/pm 174 T i n n i t u s Q u e s t i o n n a i r e ( c o n t ) 13. Which of t h e - f o l l o w i n g g e n e r a l l y seem t o c a u s e an INCREASE or a DECREASE i n y o u r t i n n i t u s l e v e l ? PLEASE WRITE + IN THE FIRST COLUMN OPPOSITE THE WORDS WHICH CAUSE AN INCREASE IN YOUR TINNITUS LEVEL. WRITE - IN THE SECOND COLUMN OPPOSITE THE WORDS WHICH CAUSE A DECREASE IN YOUR TINNITUS LEVEL. (+) (-) ca u s e s an c a u s e s a i n c r e a s e d e c r e a s e / / a l c o h o l / / / / c o f f e e / / / / t e a / / / / e a t i n g / / / / f e e l i n g r e l a x e d / / / / weather c h a n g e s / / / / massage / / / / f e e l i n g d e p r e s s e d / / / / w h i l e r e s t i n g / / / / w a t c h i n g TV / / / / l i s t e n i n g t o r a d i o / / / / s t r e s s / t e n s i o n / / / / b r i g h t l i g h t s / / / / f a t i g u e / / / / n o i s y e n v i r o n m e n t / / / / q u i e t e n v i r o n m e n t / / / / w h i l e d o i n g a t a s k / / / / e x e r c i s e / / THAN K YOU FOR "THIS INFORMAT-175 Appendi;; J PROTOCOL FOR ATTENTION FOCUS GROUP PREPARATION 1. A s s e m b l e -forms and w r i t e s u b j e c t number on e a c h . 2. Make s u r e t h a t t h e camera and m a g a z i n e s a r e b e h i n d t h e s c r e e n . 3. S e a t s u b j e c t and ask s u b j e c t t o s i g n c o n s e n t -form ("e" v e r s i o n ) . GIVE SUBJECT A COPY. 4. R e c o r d s t a r t i n g t i m e f r o m your watch on t h e H e a r t - R a t e f o r m . ADAPTATION 5. A t t a c h h e a r t - r a t e meter t o l i t t l e f i n g e r of t h e s u b j e c t ' s n on-dominant hand. E x p l a i n what i t i s b u t DO NOT show r e a d i n g t o sub i e c t . ASK SUBJECT WHETHER HE/SHE CAN UNDERSTAND YOUR SPEECH. 6. Ask s u b j e c t t o s i t q u i e t l y and r e l a x . DO NOT TALK TO SUBJECT APART FROM ANSWERING QUESTIONS ABOUT FORMS. 7. S t a r t s t o o - w a t c h . 8. In t h e f i r s t m i n u t e s t a r t i n g a t 10 s e c o n d s t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 9. Ask s u b j e c t t o c o m p l e t e t h e s e f o r m s IN THIS ORDER: h e a r i n g a b i l i t v s c a l e t i n n i t u s q u e s t i o n n a i r e * * **** A f t e r s u b i e c t c o m p l e t e s e a c h f o r m i n t h i s r e s e a r c h , PLEASE SCAN EACH* FORM AND CHECK THAT IT HAS BEEN FULLY AND CORRECTLY COMPLETED b e f o r e c o n t i n u i n g . * * * * * * 10. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 11. Check t i m e on s t o p - w a t c h . If < 9 m i n u t e s have e l a p s e d , ask s u b j e c t t o s i t q u i e t l y and a f t e r 9 m i n u t e s go t o s t e p 11. I f > o r = 9 m i n u t e s , go t o s t e p 11. 176 ATTENTION FOCUS FROTOCOL 12. Take 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 13. Then ask s u b j e c t t o c o m p l e t e RAS. 14. Then r e c o r d t i m e f r o m s t o p - w a t c h , on t h e H e a r t - r a t e s h e e t . 15. R e s e t s t o o - w a t c h t o z e r o . MANIPULATION 16. Read t h e t i n n i t u s f o c u s s c r i p t SLOWLY AND CLEARLY: "I would l i k e you t o f o c u s on y o u r t i n n i t u s s o u n d . T r y t o d i r e c t y o u r a t t e n t i o n a s much as you can t o a l l a s p e c t s o f t h e t i n n i t u s s ound: what t h e sound i s . whether i t seems l o u d e r or s o f t e r t h a n u s u a l , whether you a r e h e a r i n g i t i n b o t h e a r s o r i n one e a r . what t h e sound r e m i n d s you o f . P l e a s e c l o s e y o u r e y e s now and t r y t o keep y o u r a t t e n t i o n f o c u s s e d on y o u r t i n n i t u s sound f o r t h e n e x t few m i n u t e s u n t i l I ask you t o s t o p . PLEASE BEGIN TO FOCUS ON YOUR TINNITUS SOUND NOW." 17. S t a r t stoD-watch and. s t a r t i n g a t 10 s e c o n d s , t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 18. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 2 mins and 10 s e e s . 19. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 20. S t o p s t o p - w a t c h and r e s e t t o z e r o . REVERSAL 21. Sav t o s u b j e c t : " P l e a s e open y o u r e y e s and s t o p f o c u s s i n g on y o u r t i n n i t u s . P l e a s e c o m p l e t e t h e s e f o r m s . " 22. A d m i n i s t e r F o c u s V e r i f i c a t i o n ("t" v e r s i o n ) and a f t e r w a r d s t h e RAS. 23. Sav t o s u b j e c t : " P l e a s e s t o p f o c u s s i n g on y o u r t i n n i t u s now. J u s t s i t q u i e t l y and r e l a x f o r a few m i n u t e s STARTING NOW. " 24. S t a r t s t o p - w a t c h and, s t a r t i n g a t 10 s e c o n d s , t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 177 ATTENTION FOCUS FROTOCOL 25. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 2 mins and 10 s e e s . 26. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 27. Then a d m i n i s t e r - f i r s t t h e F V - p o s t and a f t e r w a r d s t h e RAS. CONCLUSION 28. D i s c o n n e c t h e a r t - r a t e meter. 29. DEBRIEFING. E x p l a i n t o s u b j e c t : "The p u r p o s e of what we d i d d u r i n g t h i s t i m e was t o examine t h e e f f e c t o f f o c u s s i n g y o u r a t t e n t i o n on y o u r t i n n i t u s . We were t r y i n g t o f i n d o u t whether f o c u s s i n g on t i n n i t u s i s l i n k e d t o t h e way you p e r c e i v e i t . " 30. E x p l a i n t o s u b j e c t how t o keep t h e T i n n i t u s D i a r y : - B r i e f l y f l i p t h r o u g h p a g e s t o show t h a t e a c h page h a s a t i m e on i t and t h a t t h e r e a r e f o u r t i m e s p e r day. -Ask s u b j e c t t o e n t e r t h e i r r a t i n g s o f mood and t i n n i t u s a t t h e t i m e s s t a t e d a t t h e t o p of e a c h page f o u r t i m e s d a i l y . Ask s u b j e c t t o t a k e d i a r y p a g e s w i t h them i f t h e y a r e away f r o m home. - S t r e s s t h e i m p o r t a n c e of d o i n g i t a t t h e t i m e s t a t e d and n o t t r y i n g t o remember a t some l a t e r t i m e what t h e t i n n i t u s was l i k e a t t h e t i m e w r i t t e n on d i a r y page. -Get s u b j e c t t o p r a c t i c e c o m p l e t i n g BOTH BACK AND FRONT o f one sample d i a r y page ( s u p p l i e d by you and n o t f r o m t h e i r h o m e - r e c o r d s e t ) by a c t u a l l y m a r k i n g X's on s c a l e s . - E x p l a i n t h a t t h e y a r e t o d e t a c h e a c h page a f t e r c o m p l e t i o n and i n s e r t i t i n t h e e n v e l o p e p r o v i d e d . Ask them t o m a i l t h e e n v e l o p e when t h e y have c o m p l e t e d t h e s e t of f o r m s which w i l l t a k e s e v e n d a y s . 31. Thank s u b j e c t and ask i f t h e r e a r e any q u e s t i o n s . 32. RECORD FINISHING TIME FROM YOUR WATCH ON THE HEART-RATE FORM. 178 Appendix K PROTOCOL FOR ANXIETY GROUP PREPARATION 1. A s s e m b l e -forms and w r i t e s u b j e c t number on each. 2. Make s u r e t h a t t h e camera and m a g a z i n e s a r e b e h i n d t h e s c r e e n . 3. S e a t s u b j e c t and ask s u b j e c t t o s i g n c o n s e n t -form ("e" v e r s i on) . GIVE SUBJECT A COPY. 4. R e c o r d s t a r t i n g t i m e -from y o u r watch on t h e H e a r t - r a t e •form. ADAPTATION 5. A t t a c h h e a r t - r a t e meter t o l i t t l e f i n g e r of t h e s u b j e c t ' s n on-dominant hand. E x p l a i n what i t i s b u t DO NOT show r e a d i n g t o s u b j e c t . ASK THE SUBJECT WHETHER HE/SHE CAN UNDERSTAND YOUR SPEECH. 6. Ask s u b j e c t t o s i t q u i e t l y and r e l a x . DO NOT TALK TO THE SUBJECT APART FROM ANSWERING QUESTIONS ABOUT FORMS. 7. S t a r t s t o o - w a t c h . 8. In t h e f i r s t m i n u t e s t a r t i n o a t 10 s e c o n d s t a k e b h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 9. Ask s u b j e c t t o c o m p l e t e t h e s e f o r m s IN THIS ORDER: h e a r i n g a b i l i t y s c a l e t i n n i t u s q u e s t i o n n a i r e ****** A f t e r s u b j e c t c o m p l e t e s e a c h f o r m i n t h i s r e s e a r c h , PLEASE SCAN EACH FORM AND CHECK THAT IT HAS BEEN FULLY AND CORRECTLY COMPLETED b e f o r e c o n t i n u i n g . * * * * * * 10. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 11. Check t i m e on s t o p - w a t c h . I f < 9 m i n u t e s have e l a p s e d , ask s u b j e c t t o s i t q u i e t l y and a f t e r 9 m i n u t e s go t o s t e p 11. I f > o r = 9 m i n u t e s , go t o s t e p 11. 179 ANXIETY GROUP PROTOCOL 12. Take 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 13. Then ask s u b j e c t t o c o m p l e t e RAS. 14. Then r e c o r d t i m e -from s t o p - w a t c h on t h e H e a r t - r a t e s h e e t . 15. R e s e t s t o p - w a t c h t o z e r o . MANIPULATION 16. Hand out one s e t of Number V i g i l a n c e S h e e t s t o each s u b j e c t . 17. Ask s u b i e c t t o r e a d t o p page and t o do t h e p r a c t i c e t a s k ONLY. IS. Check t h e p r a c t i c e r e s p o n s e s t o s e e i-f t h e y a r e done c o r r e c t l y , ask -for q u e r i e s , and answer any (but o n l y by r e p e a t i n g i n s t r u c t i o n s on -form o r g i v e n v e r b a l l y ) . 19. Say: "Now t u r n t h e page and, when I t e L l you t o , s t a r t w i t h t h e numbers on t h i s page. When you have c o m p l e t e d t h a t one, p l e a s e c o n t i n u e w i t h t h e - f o l l o w i n g p a g e s one a f t e r t h e o t h e r . " 20. Move t h e s c r e e n t o e x p o s e t h e v i d e o camera. 21. Say: "When I t u r n t h e v i d e o camera on, a p i c t u r e of you w i l l be t r a n s m i t t e d t o a l a b n e x t door where two p s y c h o l o g i s t s w i l l o b s e r v e you a s you mark t h e numbers o f f . A v i d e o r e c o r d i n g w i l l be made and o b s e r v e d l a t e r t o s t u d y y o u r r e a c t i o n s . " 22. Say " B e g i n " and s t a r t t h e s t o p - w a t c h . 23. S t a r t i n g a t 10 s e c o n d s , t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 24. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 2 mins and 10 s e e s . 25. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 26. At t h e end of t h e 5 t h m i n u t e s a y " S t o p , " s t o p t h e s t o p - w a t c h , and r e s e t t o z e r o . 27. A d m i n i s t e r F o c u s V e r i f i c a t i o n ("n" v e r s i o n ) and a f t e r w a r d s t h e RAS. REVERSAL 180 ANXIETY GROUP PROTOCOL 28. DEBRIEFING: "I would l i k e t o e x p l a i n why I t o l d you t h a t t h e r e would be someone w a t c h i n g you o v e r t h e v i d e o . In -fact t h e r e was no-one t h e r e and t h e camera was n o t c o n n e c t e d t o a n y t h i n g . (DRAW BACK CURTAIN TO SHOW T H I S ) . The p u r p o s e o-f t e l l i n g you t h a t someone would be w a t c h i n g you was t o make you a l i t t l e a n x i o u s . We a r e t r y i n g t o f i n d o u t whether a n x i e t y l e v e l s a r e l i n k e d t o t i n n i t u s i n some way and t h a t i s why we needed t o i n d u c e a l i t t l e a n x i e t y i n you. Any q u e s t i o n s ? " 29. Say t o s u b j e c t : "Now I'd l i k e you j u s t t o s i t q u i e t l y and r e l a x f o r a few m i n u t e s . " 30. S t a r t s t o p - w a t c h . 31. B e g i n n i n g a t 10 s e c o n d s , t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 32. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 2 mins and 10 s e e s . 33. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 34. Then a d m i n i s t e r f i r s t t h e F V - p o s t and a f t e r w a r d s t h e RAS. CONCLUSION 35. D i s c o n n e c t h e a r t - r a t e meter. 36. E x p l a i n t o s u b j e c t how t o keep t h e T i n n i t u s D i a r y : - B r i e f l y f l i p t h r o u g h p a g e s t o show t h a t each page has a t i m e on i t and t h a t t h e r e a r e f o u r t i m e s per day. -Ask s u b j e c t t o e n t e r t h e i r r a t i n g s of mood and t i n n i t u s a t t h e t i m e s s t a t e d a t t h e t o p of each page f o u r t i m e s d a i l y . Ask s u b j e c t t o t a k e d i a r y p ages w i t h them i f t h e y a r e away f r o m home. - S t r e s s t h e i m p o r t a n c e of d o i n g i t a t t h e t i m e s t a t e d and no t t r y i n g t o remember a t some l a t e r t i m e what t h e t i n n i t u s was l i k e a t t h e t i m e w r i t t e n on d i a r y page. -Get s u b j e c t t o p r a c t i c e c o m p l e t i n g BOTH BACK AND FRONT o f one sample d i a r y page ( s u p p l i e d by you and not f r o m t h e i r h o m e - r e c o r d s e t ) by a c t u a l l y m a r k i n g X's on s c a l e s . 181 ANXIETY GROUP PROTOCOL - E x p l a i n t h a t t h e y a r e t o d e t a c h each page a f t e r c o m p l e t i o n and i n s e r t i t i n t h e e n v e l o p e p r o v i d e d . Ask them t o m a i l t h e e n v e l o p e when t h e y have c o m p l e t e d t h e s e t o-f f o r m s w h i c h w i l l t a k e s e v e n days. 37. Thank s u b j e c t and ask i f t h e r e a r e any q u e s t i o n s . 38. RECORD FINISHING TIME FROM YOUR WATCH ON THE HEART-RATE FORM. 182 Appendi;; L PROTOCOL FOR FATIGUE GROUP PREPARATION 1. Assemble f o r m s and w r i t e s u b j e c t number on e a c h . 2. Make s u r e t h a t t h e camera and m a g a z i n e s a r e b e h i n d t h e s c r e e n . 3. S e a t s u b j e c t and ask s u b j e c t t o s i g n C o n s e n t Form ("e" v e r s i o n ) . GIVE SUBJECT A COPY. 4. F;ecord s t a r t i n g t i m e f r o m your watch on t h e H e a r t - r a t e f orm. ADAPTATION 5. A t t a c h h e a r t - r a t e meter t o l i t t l e f i n g e r of t h e s u b j e c t ' s non-dominant hand. E x p l a i n what i t i s but DO NOT show r e a d i n g t o s u b j e c t . ASK THE SUBJECT WHETHER HE/SHE CAN UNDERSTAND YOUR SPEECH. 6. Ask s u b j e c t t o s i t q u i e t l v and r e l a x . DO NOT TALK TO SUBJECT APART FROM ANSWERING QUESTIONS ABOUT FORMS. 7. S t a r t s t o p - w a t c h . 8. In t h e f i r s t m i n u t e , s t a r t i n g a t 10 s e c o n d s , t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 9. Then ask s u b j e c t t o c o m p l e t e t h e s e f o r m s IN THIS ORDER: h e a r i n g a b i l i t y s c a l e t i n n i t u s q u e s t i o n n a i r e ****** A f t e r s u b i e c t c o m p l e t e s each form i n t h i s r e s e a r c h , PLEASE SCAN EACH*FORM AND CHECK THAT IT HAS BEEN FULLY AND CORRECTLY COMPLETED b e f o r e c o n t i n u i n g . * * * * * * 10. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n o a t 4 mins and 10 s e e s . 11. Check t i m e on s t o p - w a t c h . If < 9 m i n u t e s have e l a p s e d , ask s u b j e c t t o s i t q u i e t l y and a f t e r 9 m i n u t e s , go t o s t e p 12. I f > or = 9 m i n u t e s , go t o s t e p 12. 183 FATIGUE GROUF PROTOCOL 12. Take 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 13. Then ask s u b j e c t t o c o m p l e t e RAS. 14. Then r e c o r d t i m e from s t o p - w a t c h on H e a r t - r a t e f o r m . 15. R e s e t s t o o - w a t c h t o z e r o . MANIPULATION 16. Hand out one s e t of Number V i g i l a n c e S h e e t s t o t h e s u b j e c t . 17. Ask s u b j e c t t o r e a d t h e t o p page and t o do t h e p r a c t i c e t a s k ONLY. 18. Check t h e p r a c t i c e r e s p o n s e s t o s e e i f t h e y a r e done c o r r e c t l y , ask f o r q u e r i e s , and answer any (but o n l y by r e p e a t i n g i n s t r u c t i o n s on form or g i v e n v e r b a l l y ) . 19. Say: "Now t u r n t h e page and, when I t e l l y o u t o , s t a r t w i t h t h e numbers on t h i s page. When you have c o m p l e t e d t h a t one, p l e a s e c o n t i n u e w i t h t h e f o l l o w i n g p a g e s one a f t e r t h e o t h e r . 20. Say: " B e g i n " and s t a r t t h e s t o p - w a t c h . 21. In t h e f i r s t m i n u t e , s t a r t i n g a t 10 s e e s , t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 22. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 2 mins and 10 s e e s . 23. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 24. At t h e end of t h e 5 t h mi n u t e s a y " S t o p " , s t o p t h e s t o p - w a t c h , and r e s e t t o z e r o . 25. A d m i n i s t e r FV-n and a f t e r w a r d s t h e RAS. 26. Sav t o s u b j e c t : " F i n d t h e p l a c e on t h e number s h e e t s t h a t you s t o p p e d a t and, when I t e l l you t o , p l e a s e s t a r t c r o s s i n g o u t numbers a g a i n . " 27. Say " B e g i n " and s t a r t s t o p - w a t c h . 28. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 2 mins and 10 s e e s . 29. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 184 FATIGUE GROUP PROTOCOL 50. At t h e end of t h e 5 t h m i n u t e s a y " S t o p " , s t o p t h e s t o p - w a t c h , and r e s e t t o z e r o . 51. A d m i n i s t e r FV-n and a f t e r w a r d s t h e RAS. ***** INFECT THE FATIGUE SCALE ON THE RAS. IF FATIGUE RATING HAS INCREASED BY 2 OR MORE UNITS. GO TO STEP 50 ** * * * * * * 52. Sav t o s u b j e c t : " F i n d t h e p l a c e on t h e number s h e e t s t h a t you s t o p p e d a t and, when I t e l l y o u t o , p l e a s e s t a r t c r o s s i n g o u t numbers a g a i n . " 55. Say " B e g i n " and s t a r t s t o p - w a t c h . 54. In t h e 7 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 6 mins and 10 s e e s . 35. In t h e 15th m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 14 mins and 10 s e e s . 36. At the end of t h e 15th m i n u t e s a y " S t o p " , s t o p t h e s t o p - w a t c h , and r e s e t t o z e r o . 37. A d m i n i s t e r FV-n and a f t e r w a r d s t h e RAS. ***** INFECT THE FATIGUE SCALE ON THE RAS. IF FATIGUE RATING HAS INCREASED BY 2 OR MORE UNITS, GO TO STEP 50 ***** * * * 38. Say t o s u b j e c t : " F i n d t h e p l a c e on t h e number s h e e t s t h a t you s t o p p e d a t and, when I t e l l you t o , p l e a s e s t a r t c r o s s i n g o u t numbers a g a i n . " 39. Sav " B e g i n " and s t a r t s t o p - w a t c h . 40. In t h e 7 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 6 mins and 10 s e e s . 41. In t h e 15th m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 14 mins and 10 s e e s . 42. At t h e end of t h e 15th m i n u t e s a y " S t o p " , s t o o t h e s t o p - w a t c h , and r e s e t t o z e r o . 43. A d m i n i s t e r FV-n and a f t e r w a r d s t h e RAS. ***** INFECT THE FATIGUE SCALE ON THE RAS. IF FATIGUE RATING HAS INCREASED BY 2 OR MORE UNITS, GO TO STEP 50 * * * * * * * * 44. Say t o s u b j e c t : " F i n d t h e p l a c e on t h e number s h e e t s t h a t you s t o p p e d a t and, when I t e l l you t o , p l e a s e s t a r t c r o s s i n g o u t numbers a g a i n . " 185 FATIGUE GROUP PROTOCOL 45. Say " B e g i n " and s t a r t s t o o - w a t c h . 46. In t h e 7 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 6 mins and 10 s e e s . 47. In t h e 15rd m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 14 mins and 10 s e e s . 48. At t h e end o-f t h e 15th m i n u t e s a y " S t o p " , s t o p t h e s t o p - w a t c h , and r e s e t t o z e r o . 49. A d m i n i s t e r FV-n and a f t e r w a r d s t h e RAS. CONCLUSION 50. D i s c o n n e c t t h e h e a r t - r a t e meter. 51. DEBRIEFING: E x p l a i n t o s u b j e c t "The p u r p o s e of what we d i d d u r i n g t h i s t i m e w i t h you was t o make you m i l d l y f a t i g u e d . We were t r y i n g t o f i n d o u t whether f a t i g u e l e v e l s a r e l i n k e d t o t i n n i t u s i n some way." 52. E x p l a i n t o s u b j e c t how t o keep t h e T i n n i t u s D i a r y : - B r i e f l y f l i p t h r o u g h pages t o show t h a t each page h a s a t i m e on i t and t h a t t h e r e a r e f o u r t i m e s p e r day. -Ask s u b j e c t t o e n t e r t h e i r r a t i n g s o f mood and t i n n i t u s a t t h e t i m e s s t a t e d a t t h e top of e a c h page f o u r t i m e s d a i l y . Ask s u b j e c t t o t a k e d i a r y p ages w i t h them i f t h e y a r e away f r o m home. - S t r e s s t h e i m p o r t a n c e of d o i n g i t a t t h e t i m e s t a t e d and n o t t r y i n g t o remember a t some l a t e r t i m e what t h e t i n n i t u s was l i k e a t t h e t i m e w r i t t e n on d i a r y page. -Get s u b j e c t t o p r a c t i c e c o m p l e t i n g BOTH BACK AND FRONT of one sample d i a r y page ( s u p p l i e d by you and n o t f r o m t h e i r h o m e - r e c o r d s e t ) by a c t u a l l y m a r k i n g X's on s c a l e s . - E x p l a i n t h a t t h e y a r e t o d e t a c h each page a f t e r c o m p l e t i o n and i n s e r t i t i n t h e e n v e l o p e p r o v i d e d . Ask them t o m a i l t h e e n v e l o p e when t h e y have c o m p l e t e d t h e s e t of f o r m s which w i l l t a k e s e v e n d a y s . 53. Thank s u b j e c t and ask i f t h e r e a r e any q u e s t i o n s . 54. RECORD FINISHING TIME FROM YOUR WATCH ON THE HEART-RATE FORM. 186 Appendix M PROTOCOL FOR CONTROL GROUP PREPARATION 1. A s s e m b l e -forms and w r i t e s u b j e c t number on e a c h . 2. Make s u r e t h a t t h e camera and m a g a z i n e s a r e b e h i n d t h e s c r e e n . " I 3. S e a t s u b j e c t and ask s u b j e c t t o s i g n C o n s e n t Form ("c" v e r s i o n ) . G i v e s u b j e c t a c o p y . 4. R e c o r d s t a r t i n g t i m e -from y o u r watch on t h e H e a r t - r a t e f o r m . ADAPTATION 5. A t t a c h h e a r t - r a t e meter t o l i t t l e f i n g e r of t h e s u b j e c t ' s non-dominant hand. E x p l a i n what i t i s b u t DO NOT show r e a d i n ~ t o s u b j e c t . ASK THE SUBJECT WHETHER HE/SHE CAN UNDERSTAND YOUR SPEECH 6. Ask s u b j e c t t o s i t q u i e t l v and r e l a x . DO NOT TALK TO SUBJECT APART FROM ANSWERING QUESTIONS ABOUT FORMS. 7. S t a r t s t o o - w a t c h . 8. In t h e f i r s t m i n u t e , s t a r t i n g a t 10 seconds,- t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 9. Then ask s u b j e c t t o c o m p l e t e t h e s e f o r m s IN THIS ORDER: h e a r i n g a b i l i t y s c a l e t i n n i t u s q u e s t i o n n a i r e ****** A f t e r s u b j e c t c o m p l e t e s e a c h f o r m i n t h i s r e s e a r c h , PLEASE SCAN EACH FORM AND CHECK THAT IT HAS BEEN FULLY AND CORRECTLY COMPLETED b e f o r e c o n t i n u i n g . * * * * * * 10. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s , s t a r t i n g a t 4 mins and 10 s e e s . 11. Check t i m e on s t o p - w a t c h . If < 9 m i n u t e s have e l a p s e d , ask s u b j e c t t o s i t q u i e t l v and a f t e r 9 m i n u t e s , go t o s t e p 12 I f > o r - 9 m i n u t e s , go t o s t e 12. 12. Take 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s . 187 CONTROL GOUP PROTOCOL 13. Then ask s u b i e c t t o c o m o l e t e RAS. 14. Then r e c o r d t i m e f r o m s t o p - w a t c h on H e a r t - r a t e f o r m . 15. R e s e t s t o p - w a t c h t o z e r o . MANIPULATION 16. P l a c e 15 c o p i e s of t h e N a t i o n a l G e o g r a p h i c M a g a z i n e i n t h e c e n t r e of t h e t a b l e i n f r o n t of t h e sub i e c t . 17. Hand s u b j e c t a R e a d i n g L i s t . 18. Sav: "In t h i s r e s e a r c h we need t o s e e whether j u s t b e i n g i n t h i s room w i t h o u t d o i n g any of t h e more complex t a s k s , h as an e f f e c t on s u b j e c t s ' t i n n i t u s . T h i s i s why we a s k e d vou t o come t o d a y . We need you h e r e j u s t t o r e l a x and t o c o m p l e t e some s i m p l e f o r m s . When I ask you t o , p l e a s e s t a r t r e a d i n g or b r o w s i n g t h r o u g h t h e s e m a g a z i n e s . When you have f i n i s h e d one. w r i t e t h e r e d number which i s on t h e magazine c o v e r (INDICATE) on your r e a d i n g l i s t . Then t a k e a n o t h e r m a g a z i n e of y o u r c h o i c e . T h e r e w i l l be no q u e s t i o n s a b o u t what you r e a d , s o p l e a s e j u s t e n j o y t h e m a g a z i n e s . Any q u e s t i o n s ? " 19. Say: " B e g i n " and s t a r t t h e s t o p - w a t c h . 20. In t h e 1st m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n q a t 10 s e c o n d s . 21. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 2 m i n u t e s and 10 s e c o n d s . 22. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 4 m i n u t e s and 10 s e c o n d s . 23. At t h e and of t h e 5 t h m i n u t e s a v " S t o p " and s t o p t h e s t o p - w a t c h . 24. A d m i n i s t e r F o c u s V e r i f i c a t i o n ("r" v e r s i o n ) and a f t e r w a r d s t h e RAS. 25. Sav "Now p l e a s e c o n t i n u e r e a d i n g " and s t a r t t h e s t o p - w a t c h . 26. In t h e 3 r d m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 2 m i n u t e s and 10 s e c o n d s . 27. In t h e 5 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 4 m i n u t e s and 10 s e c o n d s . 28. At t h e end of t h e 5 t h m i n u t e s a v " S t o p " and s t o p t h e 188 CONTROL SOUP PROTOCOL s t o n - w a t c h . 29. A d m i n i s t e r F o c u s V e r i f i c a t i o n ("r" v e r s i o n ) and a f t e r w a r d s t h e RAS. 30. Sav: "Now p l e a s e c o n t i n u e r e a d i n g " and s t a r t t h e s t o p - w a t c h . 31. In t h e 7 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 6 m i n u t e s and 10 s e c o n d s . 32. In t h e 15th m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 14 m i n u t e s and 10 s e c o n d s . 33. At t h e end of t h e 15th m i n u t e s a v " S t o p " and s t o p t h e s t o p - w a t c h . 34. A d m i n i s t e r F V - r and t h e n t h e RAS. 35. Say: "Now p l e a s e c o n t i n u e r e a d i n g " and s t a r t t h e s t o p - w a t c h . 36. In t h e 7 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 6 m i n u t e s and 10 s e c o n d s . 37. In t h e 15th m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 14 m i n u t e s and 10 s e c o n d s . 38. At t h e end of t h e 15th m i n u t e s a v " S t o p " and s t o p t h e s t o p - w a t c h . 39. A d m i n i s t e r F V - r and t h e n t h e RAS. 40. Say: "Now p l e a s e c o n t i n u e r e a d i n g " and s t a r t t h e s t o p - w a t c h . 41. In t h e 7 t h m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 6 m i n u t e s and 10 s e c o n d s . 42. In t h e 15th m i n u t e t a k e 6 h e a r t - r a t e r e a d i n g s a t 10 s e c o n d i n t e r v a l s s t a r t i n g a t 14 m i n u t e s and 10 s e c o n d s . 43. At t h e end of t h e 15th m i n u t e s a v " S t o p " and s t o p t h e s t o p - w a t c h . 44. A d m i n i s t e r F V - r and t h e n t h e RAS. CONCLUSION 45. D i s c o n n e c t t h e h e a r t - r a t e meter. 46. E x p l a i n t o s u b j e c t how t o keep t h e T i n n i t u s D i a r y : 189 CONTROL GDUP PROTOCOL - B r i e - f l y f l i p t h r o u g h pages t o show t h a t each page h a s a t i m e on i t and t h a t t h e r e a r e f o u r t i m e s p e r day. -Ask s u b j e c t t o e n t e r t h e i r r a t i n g s of mood and t i n n i t u s a t t h e t i m e s s t a t e d a t t h e t o p of each page f o u r t i m e s d a i l y . Ask s u b j e c t ' t o t a k e d i a r y p ages w i t h them i f t h e v a r e away f r o m home. - S t r e s s t h e i m p o r t a n c e of d o i n g i t a t t h e t i m e s t a t e d and n o t t r y i n g t o remember a t some l a t e r t i m e what t h e t i n n i t u s was l i k e a t t h e t i m e w r i t t e n on d i a r y page. -Get s u b j e c t t o p r a c t i c e c o m p l e t i n g BOTH BACK AND FRONT of one sample d i a r y page ( s u p p l i e d by you and not f r o m t h e i r h o m e - r e c o r d s e t ) by a c t u a l l y m a r k i n g X's on s c a l e s . - E x p l a i n t h a t t h e y a r e t o d e t a c h each page a f t e r c o m p l e t i o n and i n s e r t i t i n t h e e n v e l o p e p r o v i d e d . Ask them t o m a i l t h e e n v e l o p e when t h e y have c o m p l e t e d t h e s e t of f o r m s which w i l l t a k e s e v e n d a y s . 47. Thank s u b j e c t and ask i f t h e r e a r e any q u e s t i o n s . 48. RECORD FINISHING TIME FROM YOUR WATCH ON THE HEART-RATE FORM. 190 Appendix N R e a d i n g L i s t S u b j e c t number As you s e l e c t a magazine t o l o o k a t , p l e a s e w r i t e on t h i s l i s t t h e RED LETTERS which a r e on t h e c o v e r o-f t h e magazine. 1 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 191 Appendix 0 Reasons f o r Respondents Not P a r t i c i p a t i n g a. F a i l u r e t o meet c r i t e r i a 30 u n w i l l i n g n e s s t o p a r t i c i p a t e 11 d i s c o n t i n u o u s t i n n i t u s 10 o l d e r than 75 y e a r s 6 t i n n i t u s d u r a t i o n <3 months 1 v o l u n t a r y c o n t r o l over t i n n i t u s 1 s u f f e r i n g from s e v e r e d e p r e s s i o n 1 b. A d m i n i s t r a t i v e reasons f o r n o n - p a r t i c i p a t i o n 37 no c o n v e n i e n t appointment t i m e s 23 l i v e d out of town 7 f a i l e d t o keep appointment 6 d i e d 1 T o t a l 67 192 Appendix P CONSENT FORM ( e x p e r i m e n t a l s ) S u b j e c t number I have a g r e e d t o p a r t i c i p a t e i n t h e s t u d y t i t l e d " P s y c h o l o g i c a l A s p e c t s of T i n n i t u s " b e i n g c o n d u c t e d by L e s L e a d e r o-f t h e U.B.C. P s y c h o l o g y D e p a r t m e n t . I have been in-formed o-f t h e r e q u i r e m e n t s of my p a r t i c i p a t i o n i n t h i s s t u d y , which i n v o l v e s one s e s s i o n l a s t i n g between one hour and one and a h a l f h o u r s . The p u r p o s e of t h e s t u d y i s t o f i n d o u t whether o n e ' s mood a t a p a r t i c u l a r t i m e i n f l u e n c e s o n e ' s t i n n i t u s . I am aware t h a t I w i l l c o m p l e t e s e v e r a l Q u e s t i o n n a i r e s a b o u t my t i n n i t u s and my mood d u r i n g t h e s e s s i o n and t h a t I may be r e q u i r e d t o do a s i m p l e p e n c i l and p a p e r t a s k i n v o l v i n g s c a n n i n g rows of numbers. I know t h a t a l l i n f o r m a t i o n g a t h e r e d f r o m me i n t h e c o u r s e o f t h e s t u d y i s c o n f i d e n t i a l . and t h a t t h i s c o n f i d e n t a l i t y w i l l be p r o t e c t e d by n u m e r i c a l c o d i n g . I u n d e r s t a n d t h a t , i f I so wish, I am e n t i t l e d t o . make e n q u i r i e s c o n c e r n i n g t h e p r o c e d u r e s t o e n s u r e t h a t t h e y a r e f u l l y u n d e r s t o o d . I f I wish t o t e r m i n a t e my p a r t i c i p a t i o n i n t h e s t u d y , I know t h a t I am f r e e t o do s o a t any t i m e and t h i s w i l l i n no way a f f e c t a c c e s s t o f u r t h e r t r e a t m e n t or s e r v i c e s . I HAVE RECEIVED A COPY OF THIS CONSENT FORM. I HAVE READ THIS CONSENT FORM AND AGREE TO PARTICIPATE IN THIS STUDY. S i gned D a t e 1985 193 Appendix Q CONSENT FORM ( c o n t r o l s ) S u b j e c t number I have a g r e e d t o p a r t i c i p a t e i n t h e s t u d y t i t l e d " P s y c h o l o g i c a l A s p e c t s o-f T i n n i t u s " b e i n g c o n d u c t e d by L e s L e a d e r of t h e U.B.C. P s y c h o l o g y Department. I have been i n f o r m e d of t h e r e q u i r e m e n t s of my p a r t i c i p a t i o n i n t h i s s t u d y , which i n v o l v e s one s e s s i o n l a s t i n g about one and a h a l f h o u r s . The p u r p o s e of t h e s t u d y i s t o f i n d o u t whether o n e ' s mood a t a p a r t i c u l a r t i m e i n f l u e n c e s one's t i n n i t u s . I am aware t h a t I w i l l c o m p l e t e s e v e r a l q u e s t i o n n a i r e s a b o u t my t i n n i t u s and my mood d u r i n g t h e s e s s i o n and t h a t I w i l l be r e q u i r e d t o r e a d N a t i o n a l G e o g r a p h i c m a g a z i n e s . I know t h a t a l l i n f o r m a t i o n g a t h e r e d from me i n t h e c o u r s e of t h e s t u d y i s c o n f i d e n t i a l , and t h a t t h i s c o n f i d e n t a l i t y w i l l be p r o t e c t e d by n u m e r i c a l c o d i n g . I u n d e r s t a n d t h a t , i f I s o w i s h , I am e n t i t l e d t o make e n q u i r i e s c o n c e r n i n g t h e p r o c e d u r e s t o e n s u r e t h a t t h e y a r e • f u l l y u n d e r s t o o d . If I wish t o t e r m i n a t e my p a r t i c i p a t i o n i n t h e s t u d y , I know t h a t I am f r e e t o do so a t any t i m e and t h i s w i l l i n no way a f f e c t a c c e s s t o f u r t h e r t r e a t m e n t or s e r v i c e s . I HAVE RECEIVED A COPY OF THIS CONSENT FORM. I HAVE READ THIS CONSENT FORM AND AGREE TO PARTICIPATE IN THIS STUDY. S i gned D a t e 1985 

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