Psychological Correlates of Tinnitus Handicap: Associations with Personality Traits and Emotional Distress

1. Introduction

Tinnitus is a phantom perception of sound in the absence of an external acoustic stimulus. Although tinnitus is often considered a benign auditory phenomenon, a substantial proportion of individuals experience it as a highly distressing and disabling condition that negatively affects their emotional well-being and quality of life. The perception of a severe tinnitus handicap is strongly related to the emotional system [1]. Jastreboff and Hazell described the processes a person undergoes from the emergence of tinnitus to the development of a vicious circle, resulting in the firm stabilization of the tinnitus-related pattern and the formation of an intense negative emotional reaction towards tinnitus [1]. In some patients, tinnitus can trigger or exacerbate negative emotional responses, such as depression and anxiety. In a systematic review by Meijers et al. [2], 31 out of 33 studies showed significant correlations between perceived tinnitus distress and depressive symptoms. The prevalence of clinically significant depression scores ranged from 4.6% to 41.7%. In a population-based cohort study by Hackenberg et al. [3], logistic regression results revealed that subjects with tinnitus were more likely to suffer from depression, anxiety, or somatization. A meta-analysis by Jiang et al. [4] demonstrates that tinnitus is strongly related to depression, anxiety, stress, insomnia, and suicidal ideation. They recommended that future studies include personality traits to fully assess the association between tinnitus and mental health factors. Neuroticism was the most consistently identified trait in previous studies. In a systematic review by van Munster et al. [5], nine out of 11 studies revealed a relationship between tinnitus distress and the neuroticism trait. Another systematic review [6], based on seven articles about the association between the Big Five traits and tinnitus, recognized that the neuroticism trait plays a crucial role in how intensely individuals are affected by tinnitus. A pan-European study showed inter-country differences in the prevalence of severe tinnitus distress, ranging from 0.6% to 4.2%. These geographical variations were probably shaped by socioeconomic disparities, environmental and occupational noise, and healthcare infrastructure [7]. To the best of our knowledge, no previous study in Bosnia and Herzegovina has simultaneously examined audiological, personality, and emotional predictors of tinnitus handicap using a comparison group of hearing-impaired patients without tinnitus.

The aim of this study was to evaluate the relationship between perceived tinnitus handicap and sociodemographic and clinical characteristics, personality traits, and symptoms of depression, anxiety, and stress. Based on previous findings, we hypothesized that: (H1) tinnitus handicap would be positively associated with depression, anxiety and stress; (H2) neuroticism would be positively associated with tinnitus handicap; (H3) psychological variables would explain a greater proportion of variance in tinnitus handicap than sociodemographic or audiological variables.

2. Materials and Methods

2.1. Patients and Procedures

The study investigated patients referred to our clinic with a primary complaint of tinnitus, hearing loss, or both. Patients aged 20 to 60 years were included in the study. Tinnitus duration was required to be at least four months. The exclusion criteria were as follows: age under 20 or over 60 years, normal hearing, tinnitus duration of less than four months, and a history of previous tinnitus treatment. Patients with vertigo, mental illness, or otological and neurological diseases were also excluded. The tinnitus group comprised patients suffering from both hearing loss and tinnitus. The control non-tinnitus group comprised patients with hearing loss and no tinnitus. Ethical approval was obtained from the institutional Ethics Committee.

The patients had undergone an otological medical examination and pure-tone audiometry, but they had not received any specific tinnitus therapy or counselling at the time they completed the questionnaires. After informed consent was obtained, patients completed the Tinnitus Handicap Inventory, the Depression Anxiety Stress Scales, and the Eysenck Personality Questionnaire-Revised Short Form. Sociodemographic data regarding the patients (age, sex, level of formal education) and descriptive data about the tinnitus were collected.

2.2. Measuring Instruments

Tinnitus Handicap Inventory (THI). The THI quantifies the impact of tinnitus on daily living [8]. The THI is a 25-item self-report measure comprised of three subscales: the Functional subscale (11 items), the Emotional subscale (9 items), and the Catastrophic subscale (5 items) that measure functional, emotional, and catastrophic impact of tinnitus, respectively. Each of 25 items is rated on a 3-point scale: “yes” (4 points), “sometimes” (2 points), and “no” (0 points). The total score ranges from 0 to 100. Scores are interpreted using the following categories: slight problem (0-16), mild (18-36), moderate (38-56), severe (58-76), and catastrophic (78-100) [9]. The validated Croatian version of THI was used [10]. In the present sample, the internal consistency of the THI-HR was excellent. Cronbach’s alpha coefficient was 0.963 for the total scale, 0.917 for the Functional subscale, 0.934 for the Emotional subscale, and 0.783 for the Catastrophic subscale, indicating good to excellent reliability.

Depression Anxiety Stress Scales (DASS). The DASS is a 42-item self report instrument designed to measure the three related negative emotional states of depression, anxiety and tension/stress. The DASS-Depression (14 items) focuses on reports of low mood, motivation, and self-esteem, DASS-Anxiety (14 items) on physiological arousal, perceived panic, and fear, and DASS-Stress (14 items) on tension and irritability. A participant indicates on a 4–point scale the extent to which each of 42 statements applied over the past week (from 0=did not apply to me at all to 3=applied to me very much, or most of the time). Higher scores on each subscale indicate increasing severity of depression, anxiety, or stress [11]. The Croatian version of the DASS has previously demonstrated good internal consistency, with Cronbach’s alpha coefficients of 0.87 for the Depression subscale, 0.91 for the Anxiety subscale, and 0.82 for the Stress subscale. The instrument has been widely used as a reliable measure of negative emotional states in Croatian-speaking populations [12].

Eysenck Personality Questionnaire Revised/ Short Scale (EPQ-RS). The EPQ-RS is a self-reported questionnaire that includes 48 items and four subscales: Extraversion (12 items), Neuroticism (12 items), Psychoticism (12 items), and Lie (12 items). The lie subscale is a control scale in which the whole scale is tested for social desirability bias. Each question has a binary response, “yes” or “no”. Each dichotomous item was scored 1 or 0, and each scale had a maximum possible score of 12 and minimum of zero [13]. Personality traits were assessed using the EPQ-RS, which has been standardized for Croatian-speaking populations and has demonstrated satisfactory psychometric properties in previous validation studies [14]. Therefore, the EPQ-RS was considered an appropriate instrument for assessing personality dimensions in the present study.

Perceived tinnitus pitch and loudness. Each patient subjectively rated the overall pitch and loudness of their tinnitus on a 4-point scale. For pitch scaling, a score of 1 represented a very low-pitched foghorn, whereas a score of 4 represented a very high-pitched whistle. For loudness scaling, a score of 1 represented very faint tinnitus, whereas a score of 4 represented very loud tinnitus.

2.3. Study Design

In this cross-sectional study, the perceived tinnitus handicap of the tinnitus group was evaluated using the THI questionnaire. The relationships of the THI scores with age, sex, hearing thresholds, level of formal education, tinnitus duration and loudness, DASS scores, and EPQ-RS scores were examined. DASS scores were compared across the five tinnitus severity categories. A hierarchical multiple regression analysis was conducted to identify the predictors of perceived tinnitus handicap. The tinnitus group and non-tinnitus group were compared in terms of potential confounding variables and DASS scores.

2.4. Statistical Analysis

Using a pilot study sample and the G*Power software (version 3.1.7), with a power of 0.80 and a medium effect size of 0.50, it was determined that 106 participants were needed in each group to achieve a significance level of alpha = 0.05. The normality of the distribution was tested using the Kolmogorov-Smirnov test. Relationships of perceived tinnitus handicap with age, sex, hearing impairment, and formal education were examined using the Spearman’s rank correlation coefficient for data that did not follow a normal distribution. Comparison of the central location of two independent variables was done using the Independent samples t‒test for variables not showing statistically significant deviation from Gaussian distribution on the Kolmogorov-Smirnov test and using the Mann-Whitney U test for data where deviation from Gaussian distribution was statistically significant. Correlations between scores on the THI and the other assessment measures (the DASS, the EPQ-RS), subjective tinnitus ratings) were examined using the Spearman’s rank correlation coefficient for data that did not follow a normal distribution. A hierarchical multiple regression analysis was done with a view to establishing a relative contribution of sociodemographic, audiologic, and psychologic factors and personality traits to explanation of the severity of a perceived tinnitus handicap. Internal consistency reliability was evaluated using Cronbach’s alpha coefficients. Values above 0.70 were considered indicative of acceptable reliability. Prior to conducting the hierarchical multiple regression analysis, multicollinearity diagnostics were examined. Variance Inflation Factor (VIF) and tolerance values were calculated for all predictor variables. Multicollinearity diagnostics indicated no evidence of problematic multicollinearity. Differences in depression, anxiety, and stress scores across tinnitus severity categories were examined using one-way analysis of variance (ANOVA), followed by Scheffé post hoc tests for multiple comparisons. To assess the practical significance of statistically significant group differences, effect sizes were calculated using Cohen’s d. Because significant differences in age and extraversion were observed between the tinnitus and non-tinnitus groups, analyses of covariance (ANCOVA) were additionally performed to compare depression, anxiety, and stress scores while controlling for these potential confounding variables. The level of statistical significance was set at p < 0.05. All statistical analyses were performed using SPSS for Windows (Version 13.0; SPSS Inc., Chicago, IL, USA).

3. Results

Out of 311 initial participants, 246 fully met the study criteria: 127 in the tinnitus group and 119 in the non-tinnitus control group. The sociodemographic and clinical characteristics of study patients are shown in Table 1.

3.1. Tinnitus Group

There was no statistically significant correlation between age and the total THI (r_s = 0.038, p > 0.05), functional (r_s = 0.024, p > 0.05), emotional (r_s = 0.081, p > 0.05), and catastrophic (r_s = -0.031, p > 0.05) subscale scores. Furthermore, the scatter diagram with age as an independent variable (x-axis) and with THI scores as a dependent variable (y-axis) showed a lack of correlation between the two variables.

Differences between males and females were not statistically significant across all THI subscales (Mann-Whitney U test): total (Z = -0.020, (p = 0.981), functional (Z = -0.174, p = 0.862), emotional (Z = -0.310, p = 0.757), and catastrophic (Z = -0.564, p = 0.573).

There was a statistically significant positive weak relationship between the pure tone average and total THI (r_s = 0.381, p < 0.01), functional (r_s = 0.305, p < 0.01), emotional (r_s = 0.288, p < 0.01), and catastrophic (r_s = 0.312, p < 0.01) subscale scores. Greater hearing loss was weakly correlated with a more severe tinnitus handicap.

There was a statistically significant negative weak relationship of education with total THI (r_s = -0.290, p < 0.01), functional subscale (r_s = -0.295, p < 0.01), emotional subscale (r _s= -0.284, p < 0,01), and catastrophic subscale (r_s = -0.234, p<0.01). The higher formal educational level was associated with lower perceived tinnitus handicap.

Out of 127 tinnitus sufferers, 54 (42.5%) of them had difficulties (“cannot make out”) in tinnitus pitch rating. Therefore, pitch ratings were not included in further statistical analysis.

There was a statistically significant positive weak relationship between tinnitus loudness and THI scores, total and subscale. There were statistically significant positive weak and moderate relationships of the three DASS subscales and the EPQ-RS-Neuroticism subscale with total THI and its three subscales. The connection between extraversion and THI scores was so slight that it had little practical predictive power (Table 2).

There was no significant correlation of tinnitus duration with depression (r_s = 0.015; p = 0.863), anxiety (r_s = 0.022; p = 0.809), and stress (r_s = 0.074; p = 0.407) subscale.

The five THI tinnitus severity categories (slight, mild, moderate, severe, and catastrophic) were compared in terms of their DASS scores. After a significant One-way ANOVA results, the Scheffé post-hoc test (p < 0.001) showed that patients experiencing catastrophic tinnitus reported significantly higher depression (F (4, 122) = 9.52, p < 0.001), anxiety (F(4, 122) = 14.18, p < 0.001), and stress (F(4, 122) = 11.95, p < 0.001) scores compared to those with slight, mild, or moderate tinnitus grades (Table 3).

To determine the relative contribution of sociodemographic, audiological, and psychological factors, as well as personality traits, in explaining the severity of perceived tinnitus-related distress, a hierarchical multiple regression analysis was conducted. Prior to conducting the hierarchical multiple regression analysis, multicollinearity diagnostics were examined. Variance Inflation Factor (VIF) and tolerance values were calculated for all predictor variables. The obtained VIF values ranged from 1.07 to 2.65, while tolerance values ranged from 0.378 to 0.935. Since all VIF values were below the recommended threshold of 5 and all tolerance values exceeded 0.20, multicollinearity was not considered a concern in the present analysis. The criterion variable was the total score on the THI. Subjective tinnitus loudness, neuroticism, and total emotional distress (the total DASS score) emerged as statistically significant predictors of the total THI score. Age, sex, degree of hearing loss, tinnitus duration, duration of education, extraversion, psychoticism, and the lie scale did not prove to be statistically significant predictors (Table 4). These findings illustrate the complex nature of tinnitus, highlighting that subjective perception and psychological factors have a far greater impact on the patient’s quality of life than audiological parameters or demographic characteristics themselves.

3.2. Tinnitus Group Versus Non-Tinnitus Group

Tinnitus and non-tinnitus patients were compared with respect to potential confounding factors that could influence the results of the DASS. No statistically significant differences were found between the groups regarding the male-to-female ratio (chi-square = 4.48, p = 0.057). Similarly, no significant differences were observed using Student’s t-test for the degree of hearing loss (t = -0.22, p = 0.830), level of formal education (t = -1.82, p = 0.071), duration of schooling (t = -1.82, p = 0.071), psychoticism (t = -0.15, p = 0.881), and neuroticism (t = 1.85, p = 0.066) subscale scores. Patients with tinnitus were significantly older (t = 3.64, p = 0.001), whereas those without tinnitus scored higher on the extraversion subscale (t = -2.42, p = 0.016).

To examine the effect size of the differences, Cohen’s d was calculated for the established significant differences in age and extraversion, amounting to d = 0.46 and d = -0.31, respectively. This means the age difference between the two groups was substantial and practically meaningful, not just statistically significant. Also, while there was a real difference in extraversion between the groups, the overlap between them was still relatively large.

Compared to tinnitus-free patients, tinnitus patients had statistically significantly higher scores across all DASS subscales (Mann-Whitney U test): depression (U = 5446.0, p < 0.001), anxiety (U = 4812.0, p < 0.001), and stress (U = 6560.5, p < 0001) (Table 5).

Because the tinnitus and non-tinnitus groups differed significantly in age and extraversion, additional analyses of covariance (ANCOVA) were conducted to determine whether these variables influenced the observed group differences in emotional distress. After controlling for age and extraversion, the tinnitus group continued to demonstrate significantly higher levels of depression, F(1, 242) = 11.14, p = 0.001, anxiety, F(1, 242) = 16.49, p < 0.001, and stress, F(1, 242) = 22.63, p < 0.001, compared with the non-tinnitus group. These findings indicate that the observed differences in emotional distress cannot be explained solely by differences in age or extraversion between the groups.

4. Discussion

The present study examined the relationship between tinnitus-related handicap, sociodemographic and clinical characteristics, personality traits, and symptoms of depression, anxiety, and stress in a clinical sample of patients with chronic tinnitus. Current results indicate that the perception of tinnitus is not merely a physical issue (loudness and hearing status), but is strongly linked to the individual’s psychological state (stress, anxiety, personality). Several findings deserve particular attention.

First, perceived tinnitus handicap was significantly associated with subjective tinnitus loudness, hearing loss, and educational level. Patients who reported louder tinnitus and greater hearing impairment experienced higher levels of tinnitus-related disability, whereas higher educational attainment was associated with lower handicap scores. These findings partially support previous epidemiological evidence demonstrating that hearing impairment represents one of the most important risk factors for tinnitus occurrence and severity. Biswas et al. [7], in a large pan-European survey involving more than 11,000 participants from 12 European countries, reported that tinnitus prevalence and severity increased with worsening hearing status and age. Furthermore, healthcare utilization increased proportionally with tinnitus severity, highlighting the substantial burden imposed by bothersome tinnitus.

A longitudinal self-report survey study by Devos et al. [15] showed that more perceived loudness and hearing loss were associated with the higher Tinnitus Questionnaire scores, while tinnitus sufferers with a higher education level reported lower tinnitus burden scores. In a study by Chen et al. [16], change in loudness and hearing thresholds were significantly correlated with the THI scores. Mavrogeni et al. [17] reported a significant correlation between tinnitus loudness and the total Tinnitus Severity Index (TSI) scores, but audiometric results did not affect the TSI scores. In a study by Searchfield et al. [18], there was no significant correlation between the TSI scores and audiometric parameters, but elevated low frequency thresholds were correlated with the total Tinnitus Handicap Questionnaire (THQ) score. The authors speculated that the TSI and THQ were measuring similar, but not exactly the same, tinnitus constructs.

Interestingly, although hearing loss showed significant bivariate associations with tinnitus handicap, it did not remain a significant predictor in the final regression model. Instead, subjective tinnitus loudness emerged as a stronger predictor. Consistent with this result, in a study on Italian patients [19], a linear regression model showed no significant correlation between hearing level and the total THI score. This finding suggests that patients’ subjective appraisal of tinnitus may be more important for their quality of life than objective audiological indicators. Similar conclusions have been reported previously, supporting contemporary neurophysiological models proposing that tinnitus-related suffering is determined not only by auditory dysfunction but also by cognitive and emotional processing of tinnitus signals [1,20,21].

A particularly important contribution of the present study concerns personality traits. Neuroticism demonstrated significant positive correlations with total THI scores and all THI subscales and remained an independent predictor of tinnitus handicap in the regression analysis. This finding is highly consistent with the growing body of evidence identifying neuroticism as the personality dimension most strongly associated with tinnitus distress [5]. Similarly, Bernal-Robledano et al. [6] concluded that neuroticism represents the most consistent psychological characteristic associated with tinnitus suffering across different populations and measurement instruments. Research by Simões et al. [22] showed that neuroticism and agreeableness had a positive correlation with tinnitus distress, while extraversion had a negative correlation. They identified the facets of neuroticism, emotional volatility, anxiety, and depression, and a facet of extraversion, energy level, to be significant predictors of the THI scores cross-sectionally. Further, they investigated the role of personality traits in tinnitus distress over time. The longitudinal analysis showed that the patients with improved and stable THI scores had statistically significant lower neuroticism scores and higher extraversion scores than patients with worsened tinnitus distress.

The observed association is theoretically meaningful. Neuroticism reflects a stable tendency toward emotional instability, heightened sensitivity to stress, increased worry, and a greater propensity to interpret ambiguous situations as threatening. Individuals with high neuroticism may therefore be more likely to focus attention on tinnitus-related sensations, perceive them as uncontrollable, and engage in maladaptive cognitive processes such as catastrophizing and rumination. Such mechanisms may amplify tinnitus-related distress even when objective tinnitus characteristics are comparable. Consequently, personality traits may function as vulnerability factors influencing adaptation to chronic tinnitus.

Our findings also demonstrated robust relationships between tinnitus handicap and symptoms of depression, anxiety, and stress. Moderate positive correlations were observed between all DASS dimensions and THI scores. Moreover, patients classified within the catastrophic tinnitus category exhibited significantly higher levels of depression, anxiety, and stress than patients experiencing slight, mild, or moderate tinnitus handicap. These findings are consistent with a substantial body of previous research [2,3,4,23]. The authors emphasized the necessity of incorporating psychological assessment and intervention into routine tinnitus management.

The comparison between tinnitus patients and the control group without tinnitus further strengthens the interpretation of our findings. Patients with tinnitus reported significantly higher levels of depression, anxiety, and stress despite the fact that both groups were recruited from the same clinical setting and shared hearing-related difficulties. This finding suggests that psychological distress cannot be explained solely by hearing impairment and may be specifically linked to the subjective burden imposed by tinnitus. The results therefore support the growing consensus that tinnitus should be understood as a multidimensional condition involving both auditory and psychological processes.

One of the most noteworthy findings of the present study emerged from the hierarchical regression analysis. Subjective tinnitus loudness, neuroticism, and overall emotional distress remained significant predictors of tinnitus handicap, whereas demographic variables, hearing loss severity, tinnitus duration, and other personality dimensions did not. These findings closely correspond to those reported by Strumila et al. [24], who found that anxiety symptoms, depressive symptoms, and neuroticism were among the strongest predictors of perceived tinnitus severity. Their study suggested that psychological characteristics may account for a substantial proportion of variance in tinnitus-related suffering beyond audiological factors alone.

Taken together, the findings support a biopsychosocial understanding of tinnitus. Although tinnitus often originates from auditory dysfunction, the extent to which it becomes a disabling condition appears to depend largely on psychological characteristics and emotional responses. Patients high in neuroticism and emotional distress may be particularly vulnerable to experiencing tinnitus as intrusive, threatening, and uncontrollable. Consequently, routine clinical assessment should extend beyond audiological examination and include systematic screening for depression, anxiety, stress, and maladaptive personality characteristics. Such an approach may facilitate early identification of patients at increased risk of severe tinnitus-related impairment and enable more individualized interventions, including cognitive-behavioural approaches, psychoeducation, and psychological support. These findings are consistent with contemporary evidence demonstrating that cognitive-behavioural interventions can effectively reduce tinnitus-related distress and improve psychological adjustment, even when the auditory perception itself remains unchanged [20].

Several limitations should be considered when interpreting the results. First, the cross-sectional design prevents conclusions regarding causal relationships between tinnitus severity, personality traits, and emotional distress. Longitudinal studies are needed to determine whether psychological difficulties contribute to tinnitus-related suffering or develop as a consequence of persistent tinnitus. Second, the study was conducted in a single tertiary care centre, which may limit generalizability to community populations or patients with less severe symptoms. Although the tinnitus and non-tinnitus groups differed in age and extraversion, additional covariance analyses showed that group differences in depression, anxiety, and stress remained significant after controlling for these variables. Third, all psychological variables were assessed using self-report questionnaires, which may be affected by response biases, social desirability effects, and shared method variance. An additional limitation concerns the use of the DASS. Although the DASS is a well-validated screening instrument for negative emotional states, it does not provide clinical diagnoses of depressive disorders, anxiety disorders, or stress-related conditions. Consequently, elevated scores should be interpreted as indicators of symptom severity rather than evidence of psychiatric diagnoses. Future studies would benefit from combining self-report measures with structured clinical interviews or clinician-rated assessments. Furthermore, personality was assessed using the EPQ-RS, which primarily captures broad personality dimensions and may not fully reflect more specific cognitive and emotional traits potentially relevant to tinnitus adaptation, such as resilience, coping style, catastrophizing, or psychological flexibility. Additionally, patients with previously diagnosed psychiatric disorders were excluded from the study. Although this approach reduced potential confounding effects, it may also have limited the variability of psychological symptoms and resulted in conservative estimates of the associations between tinnitus-related distress and mental health variables.

Despite these limitations, the present study contributes to the growing literature emphasizing the central role of psychological factors in tinnitus-related suffering. By simultaneously examining audiological characteristics, personality traits, emotional distress, and a non-tinnitus comparison group, the study provides a more comprehensive understanding of the factors associated with tinnitus handicap. The findings underscore the importance of integrating psychological assessment into routine tinnitus care and support interdisciplinary treatment models involving otolaryngologists, audiologists, psychologists, and mental health professionals. The present findings also suggest that tinnitus-related suffering is influenced more strongly by subjective perception and psychological functioning than by objective audiological characteristics alone.