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OBJECTIVE: Patients suffering with tinnitus are often advised to accept the noise, but few studies have examined what tinnitus acceptance entails. CONCLUSION: The TRS factors provide an alternative conceptualisation of tinnitus responding.
Keywords: adaptation, psychological, reproducibility of results, scales, tinnitus, validity of tests. Tinnitus is the perception of noise in the ears or head in the absence of an external acoustic source1-3 that is often associated with hearing loss4. The historical focus of the tinnitus distress literature has been on people's negative cognitive appraisals of tinnitus and their individual coping resources, which have been used to help explain tinnitus annoyance and the associated distress8. Thus, an alternative approach is required to identify tinnitus response pattern(s) that do lead to better tinnitus outcomes. In the literature, acceptance is described as a process of allowing or letting be, rather than avoiding, fixing, changing, or eliminating unwanted experiences that cannot be changed22. To help guide the development of the TRS, we used the Chronic Pain Acceptance Questionnaire CPAQ25, similar to the approach used by Westin, Hayes, Andersson5 in developing the TAQ. The University of New England Human Research Ethics committee assessed and evaluated all components of the present project.
Four groups of volunteers were recruited to assist with initial scale development, using the content validation guidelines of Haynes, Richard, Kubany28 and Clark, Watson29. The first contained relevant experts: a mindfulness researcher, clinical psychologist, and two health psychologists, one specialising in hearing and tinnitus. The second group had twelve university staff with chronic tinnitus (duration: 6-months to 30-years), 6 males and 6 females, aged 45 to 63 years, were recruited via an online advertisement and asked to describe their tinnitus experiences in a short interview. The third group employed 12 volunteers (from the second group) and seven more (n = 19), 9 females and 10 males, aged 45 to 70 years, were asked to complete a draft version of the TRS, and then categorize items into the subscales and provide feedback on the intelligibility of items; the items were revised in line with this feedback.
The study URL got 701 visits in the six-month data gathering period and 273 participated (39% response rate).
The 87-item prototype of theTinnitus Response Scales (TRS) was administered to both the Internet and the hard-copy samples. The Depression Anxiety and Stress Scales-2133 was used to assessed self-rated stress, anxiety and depression.
TRS items were examined empirically using exploratory (EFA) and confirmatory factor analyses (CFA). Reliability and validity of the TRS responses were assessed using responses received from 103 of the 150 people in the Internet sample who agreed to be contacted about future testing, and 41 of 50 people in the hardcopy sample who had similarly agreed, giving a total of 144 responses. TRS-defeat and tinnitus distress were log and inverse transformed due to positive skewing, but this did not change the relevant results, relative to untransformed scores. Half the Internet (n = 273) sample described tinnitus that started gradually (n = 132) and half described a sudden onset (n = 141). EFA was conducted on the TRS responses using the maximum likelihood function in SPSS, which provides the best match for the mathematical algorithm used in CFA. Several solutions resulted in clearly defined factors with simple structures, but some factors had insufficient items for subscale development. Using the above statistical criteria, 47 items were deleted and EFA was rerun using the remaining items. CFA was conducted on the 24-item TRS using AMOS, and tested the goodness-of-fit of the 1, 2, and 3 factor models, see Table 2.
Chi-square difference tests were used to determine if the 3-factor model fitted the data better than the other models. Test-retest reliability was computed for the TRS subscales, using the Internet and hard-copy samples, see Table 3.
Associations between the TRS subscales and maladjusted and effective coping (TCSQ) were examined, see Table 4. Next the validity of the TRS sub-scores was examined in relation to illness representations, using the IPQ-R subscales, see Table 7.
Finally, the validity of the TRS was examined in relation to tinnitus parameters and clinical details, using the TRS sub-scores, BATS, and TRQ as the study outcomes, in an exploratory manner, see Table 8. Using the Internet sample, an EFAshowed that the 12-item BATS had a single factor which included 5-items, explaining 57% of the item variance, see Table 9.
The Tinnitus Response Scales (TRS) describe three distinct cognitive, behavioral, and emotional response patterns termed control, defeat and acceptance. In the TRS, the acceptance and defeat sub-scores were highly inversely correlated, and in validity testing, they tended to be correlated with opposite characteristics in terms of age, tinnitus duration, cognitions, tinnitus distress and general distress; whereas the control and acceptance sub-scores were only moderately and inversely correlated with each other. In relation to tinnitus coping, high defeat and low acceptance scores explained much of the variance in maladjusted coping2,9, although only high control was related to effective coping, explaining 17% of its variance. These findings have potentially important treatment implications: first, defeat was common in people who had a recent tinnitus onset or had little knowledge about their condition, suggesting that adequate information provision is especially important in newly-diagnosed tinnitus patients.
Taken together, these results suggest that the way in which people will respond to tinnitus is likely to be governed by the severity, chronicity and novelty of the condition. Finally, we examined correlates of tinnitus severity and distress, including the three TRS subscales. Regarding the relevant literature, few prior studies have examined the above associations or they used different but analogous constructs. Further psychometric analysis of the TRS and BATS is warranted including examinations of their test sensitivity, specificity, predictive validity, and additional convergent and divergent validity.
The Tinnitus Response Scales assessed three distinct response patterns that differed in terms of their cognitive, behavioural, and emotional responses to chronic tinnitus. Paper submitted to the ITJ-SGP (Publishing Management System) on February 20, 2014; and accepted on March 18, 2014.
Development of the Tinnitus Response Scales: Factor analyses, subscale reliability and validity analyses. The present project developed and tested a new instrument to assess the mindfulnessbased constructs of acceptance, control, and defeat, in relation to the experience of chronic tinnitus. Participants were recruited from the general population and tinnitus support organizations and complete the first version of the Tinnitus Response Scales (TRS) and measures of tinnitus coping, severity and distress, general distress, illness cognitions, and tinnitus and health characteristics. Factors were shown to have high internal consistency and testretest reliabilities and differed in terms of their related cognitions, behaviour, and emotional responses to tinnitus, and their tinnitus characteristics. TRS is a brief psychometrically valid measure of tinnitus responding that appears to distinguish between adaptive and non-adaptive responses to tinnitus noise, and should prove useful as a clinical measure.
In the present project, we report on the development of the Tinnitus Response Scales (TRS) which was designed to delineate tinnitus response patterns associated with better tinnitus outcomes, using an acceptance and mindfulness psychotherapy approach5. Several tinnitus coping models and their psychometrically sound scales are described in the literature.
Therefore, in this project, we used acceptance and mindfulness psychotherapy models5 to help characterize chronic tinnitus responses. In addition, tinnitus acceptance responses have been shown to be related to less tinnitus distress20, although the authors used an earlier untested version of the TRS-acceptance subscale, which included slightly different items to those in the 24-item TRS proposed by the present project.
Thus, it is a neutral response that enables the non-judgemental perception of life situations in the present moment.
Thus, an acceptance-based approach may permit chronic tinnitus sufferers to develop skills that enable them to simply observe the tinnitus noise rather than reacting negatively to the experience. That is, control will reflect a negative primary appraisal of tinnitus noise, and a positive secondary appraisal of the availability of coping resources. They were asked to review the subscale definitions, which were refined in line with their feedback. Fifty-nine items were generated from the interviews, with approximately equal numbers of items evaluating cognitive, behavioral, and emotional responses in each of the three subscales. Several experts suggested that the tinnitus-related behavior should be more systematically examined (e.g. They were directed to the study URL for the online surveyor they could request a paper (hard-copy) version of the survey. They completed the 87-item TRS and answered several questions about their tinnitus history. They were mailed an information package and survey, and returned it anonymously or they confirmed their contact details if they wished to participate in future testing. Respondents rated the extent to which each statement applied to them or their tinnitus, using 0 to 10 rating scales, where 0 means not at all true and 10 means perfectly true. Respondents were asked to rate how often they used each strategy, using 7-point Likert scales. This 5-item measure of tinnitus severity was developed from an original pool of 12-items that asked participants about how much they were bothered by the tinnitus, frequency of the bother, how loud the noise was at worst and best, how much the noise impacted on their life and threatened their health and wellbeing, how distressing the tinnitus was currently and when it was first heard, and how much they were bothered by everyday sounds, using 0 to 10 point rating scales, with high scores indicating worse tinnitus severity. Only core features of the syndromes are included in the measure, permitting a maximal discrimination between the different symptom clusters. Test-retest reliability and convergent and divergent validity of the subscales were also assessed, using a sub-sample of respondents. Most (n = 232) described tinnitus loudness that was variable over time, and tinnitus awareness that was constant (n = 177). Correlational matrices showed many correlations above .3, thus, indicating suitability for factoring. Eigen values indicated there were 3 factors for retention, and scree plots suggested a one or three factor s olution. Following the recommendations of Kline38, multiple indices were used to assess goodness-of-fit with chi-square values and chi-square divided by degrees of freedom reported for each model. Following the recommendation of Kline38, chi-square values of the 2 and 3-factor models were subtracted from values of the 1-factor model. Test-retest reliabilities of the defeat and acceptance sub-scores were very good to excellent, and those of the control subscale were adequate to good see38, categorization of coefficients.
As expected, defeat was associated with all the states, explaining 30% of the variance in stress, 19% of the variance in anxiety, and 40% of variance in depression; suggesting that defeat was characterized by a pattern of high stress, depression, and also possible anxiety. In the present project, empirical support was provided for the scale using two community samples of people with chronic tinnitus who had similar clinical and demographic profiles to those reported elsewhere15,40,41, although their tinnitus distress was lower than that reported in prior studies14,32.
In contrast, control responses reflect a degree of agency and attempts to manage the tinnitus or its impact, whereas acceptance is defined as a neutral response to tinnitus that is reflected in lack of need for agency, and unconcern or non-reactivity to tinnitus.
Thus, the model was robust across two samples that were recruited by different mechanisms, and differed in terms of their age, tinnitus duration, and other tinnitus parameters. In addition, the three TRS subscales showed good to excellent test-retest reliabilityover 5 to 12 weeks.
These results indicate that defeat responses overlapped considerably with maladjusted coping, whereas acceptance was related to a lack of maladapted coping, and control shared some features in common with effective coping. Cognitively, defeat was related to less understanding of the tinnitus and an exaggerated perception of tinnitus threat. Cognitive features of control included a good understanding of tinnitus, high personal- and treatment-related control, but a magnified perception of tinnitus threat. Cognitive features of acceptance included moderate levels of personal control, few tinnitus threat perceptions and little seeking meaning in the tinnitus, consistent with the results of Davis & Morgan21. People may respond to tinnitus noise by trying to control it, or they may feel defeated by it, but over time, they may come to accept it, with or without assistance; although this conclusion requires substantiation using a longitudinal study.
In the latter case, the acceptance subscale of the TAQ5, Acceptance and Action Questionnaires27, and Multidimensional Health Locus of Control Scale43 may be used.
Psychology - School of Behavioural, Cognitive and Social Sciences - University of New England - Armidale - Australia. We posited that people who accept their tinnitus will fully adapt to the noise; whereas people who attempt to control the noise or are defeated by it, may be unable to adapt, and may continue to experience tinnitus distress. Further, acceptance was shown to be associated with a lack of seeking meaning in the tinnitus experience21.
The construct was initially developed for use in cognitive-behavioural-therapies such as Mindfulness-Based Cognitive Therapy22, Dialectical Behaviour Therapy23, and Acceptance and Commitment Therapy16. Further, additional items were generated in line with participant responses in a series of qualitative interviews; which resulted in the development of equal numbers of items assessing the cognitive, behavioral, and emotional aspects of tinnitus acceptance responses, as well as control and defeat subscales. Finally, tinnitus characteristics will be examined in relation to the TRS subscales making no a priori assumptions. Internet sample responses were used to explore the factor structure of the TRS, and hard-copy survey responses were used to confirm the factor structure of the TRS. The sample included 156 males and 122 females, with ages ranging from 19 to 88 years (M = 51, SD = 14.3 years). They also described their tinnitus symptoms, diagnosis, and history, related diagnoses, medication use, current tinnitus treatments, and they used a 0 to 10 scale to rate the tinnitus loudness at its worst, the frequency and degree of bother caused by the tinnitus, tinnitus distress, and impact of the noise on daily life.
Respondents were asked to rate the extent to which they experienced each state over the past week using 4-point severity and frequency subscales, with high scores indicating greater stress and distress. Test-retest reliability was assessed by examining the TRS responses at baseline and 5 to 12-weeks later. Values less than 3 on the latter statistic are better indicators of acceptable fit than chi-square39.
Respondents who completed the hard-copy version of the TRS were older than the Internet respondents, and they had had their tinnitus for substantially longer than those who completed the project online.
Interestingly, two of the original TRS-acceptance items, if my tinnitus disappeared tomorrow I might not notice it had gone for some time, and sometimes I need to focus on the tinnitus noise before I can hear it, failed to load onto this model, suggesting that these responses were not typical of the acceptance construct. However, the samples did not differ in terms of their TRS response patterns, although acceptance levels were higher, and control and defeat levels were lower in the hard-copy sample. For example, the TAQ subscale, Activity Engagement, overlaps considerably with TRS-defeat, and the TAQ subscale, Tinnitus Suppression overlapped somewhat with TRS-control. Behaviorally, defeat was associated with maladjusted coping and seeking out tinnitus treatments; whereas emotionally, it was associated with high stress, anxiety, and depression levels. Behaviorally, acceptance was only slightly or not related to maladjusted coping and tinnitus treatment-seeking, and emotionally, it was consistently unrelated to any emotional response pattern, even the absence of an emotional response. These results are somewhat consistent with our finding that young age was related to worse tinnitus severity and tinnitus distress perceptions. However, preliminary reliability and validity analyses in this paper provide encouraging results for both measures. The relationship between coping style, tinnitus severity and emotional distress in a group of tinnitus sufferers.
Tinnitus Cognitions Questionnaire: Development and Psychometric Properties of a Measure of Dysfunctional Cognitions Associated with Tinnitus. Psychological characteristics of individuals high and low in their ability to cope with tinnitus. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress.
Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment of tinnitus: a randomised controlled trial.
A randomized controlled trial of Internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus.
Mindfulness-based cognitive behaviour therapy for depression: A new approach to preventing relapse. Effects of suppression, acceptance and spontaneous coping on pain tolerance, pain intensity and distress. Content validity in psychological assessment: a functional approach to concepts and methods. The Behavioural Responses to Illness Questionnaire (BRIQ): a new predictive measure of medically unexplained symptoms following acute infection. T Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus.
The illness perception questionnaire: a new method for assessing the cognitive representation of illness.
Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects.
However, some people do not adapt, become sensitized, and may go on to suffer from tinnitus-related distress3,7.
Taken together, these results suggest that tinnitus acceptance may occur in people with less severe or distressing tinnitus or those not searching for meaning in their condition.
Thus, defeat responses will reflect a negative primary and secondary appraisal of tinnitus26. The experts reached consensus as to which items belonged to which subscale in most cases, thus, all items were retained for later analysis.
To be eligible, participants had to be 18 years or older and have had their tinnitus for one month or more. The sample was comprised of 150 males and 123 females, ranging in age from 18 to 99 years (M = 51, SD = 14.3). These statistics indicated that a 1 and 2 factor model did not achieve an adequate fit, but the 3-factor model achieved an adequate fit on all indices.
The non-fit of these particular items suggests that affected individuals were typically aware of the tinnitus, despite having developed tolerance or acceptance to it. Conceptually, these results are consonant with the small emerging literature related to tinnitus acceptance and the mindfulness-based treatment of tinnitus5,17,18. The TRS-acceptance had no analogous construct in the TAQ and it is therefore possible that the TRS has additional utility in measuring a broader range of tinnitus responses, especially since the TRS-acceptance subscale included items that tap into behavioral adaptation or habitation to tinnitus noise. However, CFA did not support this two-factor solution, nor was the solution stable in the EFA.
Convergent and divergent validity of the TRS sub-scores was also assessed, using additional measures of tinnitus coping, severity, and distress, general distress, tinnitus cognitions, and tinnitus and general health parameters. These results are consistent with the aforementioned definition of 'tinnitus acceptance', as a predominantly neutral cognitive response to tinnitus noise that involves neither concern nor bother about the noise. Finally, the study was cross-sectional in nature therefore precluding any causal inferences being made. Thus, in the present project, we expected that TRS-acceptance will be related to less severe and distressing tinnitus, and lower Illness Perception Questionnaire-consequences of illness scores, which assesses the meaning of tinnitus. In contrast, acceptance responses are characterized by neutral thoughts, emotion, and behavior or non-reactivity to tinnitus noise, such that the noise neither concerns nor bothers the person. In addition, mindfulness theory suggests that acceptance is antithetical to a range of different responses that may include defeat, helplessness, and resignation, but also control, and unwillingness16,22,23,27. These correlations helped to better delineate the tinnitus response patterns as detailed below.
In fact, defeat explained more than 75% of the variance in tinnitus distress, suggesting that perceptions of tinnitus distress were mostly influenced by feelings of defeat.
Furthermore, the more frequent use of coping strategies is related to greater tinnitus annoyance14 and control strategy use is related to greater sensitivity to ambient sound15. However, it is regarded as an active state inasmuch as it requires people to actively observe their thoughts, feelings and bodily sensations as they occur27 although definitionally, there is a lack of need for agency in these situations. The scale is reported to have good test-retest reliability and high internal consistency (Cronbach's alpha = .96). Taken together, these results suggest that tinnitus noise may be the 'wrong target' for tinnitus therapy.
That is, attempting to control one's tinnitus requires giving attention to the noise, likely reducing the potential for habituation and tinnitus adaptation; possibly intensifying the experience and leading to greater tinnitus annoyance and distress16.
Since the factor solutions were unaffected by the outliers, they were retained in all analyses.

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