Development of the International Tinnitus Inventory (ITI): A Patient-Directed Problem Questionnaire

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1 Audiological Medicine ISSN: X (Print) (Online) Journal homepage: Development of the International Tinnitus Inventory (ITI): A Patient-Directed Problem Questionnaire Veronica Kennedy, Sylviane Chéry-croze, Dafydd Stephens, Sophia Kramer, Hung Thai-van & Lionel Collet To cite this article: Veronica Kennedy, Sylviane Chéry-croze, Dafydd Stephens, Sophia Kramer, Hung Thai-van & Lionel Collet (2005) Development of the International Tinnitus Inventory (ITI): A Patient-Directed Problem Questionnaire, Audiological Medicine, 3:4, , DOI: / To link to this article: Published online: 11 Jul Submit your article to this journal Article views: 34 View related articles Full Terms & Conditions of access and use can be found at Download by: [Jordan Univ. of Science & Tech] Date: 03 October 2016, At: 18:03

2 ; 3(4): Development of the International Tinnitus Inventory (ITI): A Patient-Directed Problem Questionnaire VERONICA KENNEDY 1, SYLVIANE CHÉRY-CROZE 2, DAFYDD STEPHENS 1, SOPHIA KRAMER 4, HUNG THAI-VAN 2,3 AND LIONEL COLLET 2,3 From the 1 Welsh Hearing Institute, University Hospital of Wales, Cardiff, Wales; 2 Laboratoire Neurosciences et Systèmes Sensoriels, Université Claude Bernard, Lyon, France; 3 Service d explorations fonctionnelles ORL et audiophonologiques, Hôpital Edouard Herriot, Lyon, France; 4 Department of Audiology, VU University Medical Centre, Amsterdam, The Netherlands Kennedy V, Chéry-Croze S, Stephens D, Kramer S, Thai-Van H, Collet L. Development of the International Tinnitus Inventory (ITI): A Patient-Directed Problem Questionnaire. Audiological Medicine 2005; 3(4): Tinnitus can be a very troubling complaint but its impact may vary between individuals, both in the perceived severity and the aspects of life affected. The International Tinnitus Inventory (ITI) is an eight-item questionnaire based on the commonest patient reported complaints attributed to tinnitus. It is modelled on the International Outcomes Inventory Hearing Aids (IOI-HA) to be brief, have a clear and simple response format and be comparable across languages. The psychometric properties of the English and French versions have been examined in this paper. Preliminary results show that the ITI is a robust questionnaire. It is unifactorial, has a good response rate and high internal consistency and it is easy to interpret. Responses from the inventory relate to hearing level but not to other demographic factors. The ITI is a simple and patient friendly measure which can be a helpful tool to highlight the predominant tinnitus-related complaint(s) of the individual, thus providing useful information not only about the tinnitus but also to help plan and assess a rehabilitation programme. Key words: Tinnitus, International outcomes inventory hearing aids, IOI-HA, Questionnaire, International Tinnitus Inventory, ITI. INTRODUCTION Tinnitus is a very common condition. The reported severity may vary from a simple awareness of its presence to a perception of it being unbearable. Epidemiological data (1, 2) indicates that the prevalence of significant tinnitus in adults is 10 30% with approximately 5% of the population reporting constant tinnitus and 2 4% of adults experiencing severe annoying tinnitus. Psychoacoustical measures may provide helpful information about the characteristics of the tinnitus. However, individuals with a similar psychoacoustical pattern of tinnitus may vary markedly in the complaints they attribute to it. The tinnitus can be perceived to impact on different aspects of their life including their sense of well-being. Not only may there be a relationship between hearing loss and the degree of annoyance caused by the tinnitus (3) but hearing loss may be a factor in whether tinnitus treatment is sought (4). There is also an association between tinnitus and somatic disorders/symptoms, particularly headaches, palpitations and dizziness (5, 6, 7). Psychological distress and altered mood states, particularly high levels of anxiety and depression, are also reported in those complaining of tinnitus (7, 8). A number of instruments have been developed to assess the impact of tinnitus on an individual. However, the aim of any particular questionnaire usually reflects the particular interests of the researcher who designed the questionnaire, while the decision as to which particular questionnaire to use may vary according to the interest of the clinician and facilities available. In a recent review of tinnitus measures (9) only a few of those used in international research were considered to meet current psychometric standards with regard to reliability and validity. These include the Tinnitus Questionnaire (TQ) (10, 11), the Tinnitus Handicap Questionnaire (THQ) (12), the Subjective Tinnitus Severity Scale (STSS) (13), the Tinnitus Reaction Questionnaire (TRQ) (14) and the Tinnitus Handicap Inventory (THI) (15). They are all concerned with specific aspects of tinnitus rather than the overall impact. The features of these studies are outlined in Table 1. Some questionnaires look predominantly at the psychosocial aspects of tinnitus, e.g. Tinnitus Reaction Questionnaire (14) while others, e.g. Tinnitus Severity Questionnaire (16) predominantly look at the perceived severity of tinnitus. However, even where the interest of the measures, e.g. psychological, is similar, the questions used may address different aspects of the effects attributed to the tinnitus and the prominence attributed to any one aspect may vary (17). This can make it very # 2005 Taylor & Francis Group Ltd. ISSN X DOI /

3 Development of the International Tinnitus Inventory 229 Table 1. Characteristics of some tinnitus measures Items (i) Tinnitus measures TQ Tinnitus Questionnaire (4, 5) Rating by patient (ii) Subscales Reported aim of measure THQ Tinnitus Handicap Questionnaire (6) STSS Subjective Tinnitus Severity Scale (7) TRQ Tinnitus Reaction Questionnaire (8) THI Tinnitus Handicap Inventory (9) (i) 52 items (ii) 3 point scale rating effect of tinnitus from true, partly true to not true. (i) 27 items (ii) (i) 16 items (ii) Yes/No (i) 26 items (ii) 5 point scale rating presence of tinnitus from none to all of the time (i) 25 items (ii) Yes/Sometimes/No 1. Emotional and cognitive distress 2. Intrusiveness 3. Auditory perceptual difficulties 4. Sleep disturbances 5. Somatic complaints 1. Physical, emotional þ social effects of tinnitus 2. Hearing and communication ability 3. Individual s perception of tinnitus 1. Intrusiveness 2. Prominence of tinnitus 3. Distress 1. General distress, e.g. annoyance 2. Interference with work/leisure 3. Severe distress, e.g. crying, sleep problem, fear of being driven mad 4. Avoidance of activities 1. Functional effect of tinnitus 2. Emotional response to tinnitus 3. Catastrophic response to tinnitus *Psychological aspects of tinnitus *Assess complaints and distress of tinnitus sufferers *Measure patients perceived degree of handicap due to tinnitus *Assess severity of tinnitus *Assess psychological distress associated with tinnitus *Distinguish tinnitus sufferers who cope with tinnitus from those who do not cope well *Measure impact of tinnitus on everyday function difficult to compare complaints attributed to tinnitus across studies. Questionnaires may not translate well into other languages as it can be difficult to maintain the integrity of the question because of unintentionally different nuances of meaning and, therefore, the data obtained may not be comparable across different languages. Clinically it would be invaluable to have a questionnaire which would provide an accurate evaluation of the overall tinnitus impact in a given individual, but using only a few items and which can, therefore, be completed in a short time in a clinic setting. A short questionnaire presents other advantages: where there are only a few items, the most distressing tinnitus effects will be more prominent and also translations into various languages will be more meaningful. While Hiller and Goebel (18) recently developed an abridged version of the TQ, a useful tool for evaluating the psychological distress attributed to tinnitus, it may be helpful clinically to first be aware of the different areas in which the tinnitus is felt to cause difficulty. This led us to develop the International Tinnitus Questionnaire, a short questionnaire comprising only eight items. Our measure was constructed to be psychometrically equivalent in its translation into French allowing comparability of data between the different countries. This paper explains how the measure was designed and explores how its English and French versions were validated. METHOD Subjects Cardiff patients. The inventory was administered to 141 consecutive patients attending a tinnitus clinic at the Welsh Hearing Institute in Cardiff. The median age of the patients was 60 years (mean 61.0 years, SD 13.0 years). Sixty-four of the patients were female, 76 were male, with the gender of one patient not recorded. Forty of the patients were first time attenders at the clinic, 97 were follow-up patients. In four cases this was not specified.

4 230 V Kennedy et al. Tyler & Baker (1983) Mean no of difficulties reported: 4.59 Sanchez & Stephens (1997) Mean no of difficulties reported: 3.8 Effect on Sleep only 15% Tinnitus-specific 13% Situational 11% Auditory Perception 21% Auditory Perception 14% Sleep 13% Impact on Lifestyle (including sleep) 24% Health Effects 15% Health Effects 22% Psychological/ Emotional effect 19% Psychological/ Emotional effect 33% Fig. 1. Common complaints attributed to tinnitus (from Kennedy et al., 2004). The median duration of tinnitus was seven years (range: 1 month 57 years) with the median better ear hearing level (0.5 4 khz) 25 db HL (range db HL) and the median worse ear hearing level 36 db (range db HL). We also noted whether or not there was a family history of either tinnitus or hearing impairment. Lyon subjects. Three hundred individuals with tinnitus (195 male and 105 female) aged from 18 to 86 years (mean age: 49.4, SD 14.2 years) completed the ITI. The ITI was distributed to these individuals at meetings of tinnitus or hard of hearing patients (n = 60) and also posted on the website of the French tinnitus association France Acouphènes ( org) (n = 240). Since these patients did not attend a tinnitus clinic in the context of the study, their hearing status was assessed using a quasi-quantitative measure of hearing difficulties following TV programmes. The question was Do you have difficulty following TV programmes at a volume others find acceptable without any aid to hearing? Responses were graded from 0 to 3 (no difficulty slight difficulty moderate difficulty severe difficulty). This measure was derived from the National Study of Hearing (1) and had been used in an analysis of a previous population study (19). Item development Earlier studies (20, 21) looked at the distribution of tinnitus associated problems reported by members of a tinnitus self-help group and by clinic patients using an open-ended question (Figure 1). The range and distribution of problems reported in both studies were similar. The domains included effects on hearing, life style, general health and emotional problems with the highest importance weighting of difficulties being getting to sleep, the persistence of tinnitus and family problems. We constructed a measure based on these complaints using the format of the International Outcome Inventory Hearing Aids (IOI-HA) (22). The IOI-HA has proved to be a simple and robust measure with high patient compliance using questions designed to be unambiguous and encouraging a good response rate (23). The International Tinnitus Inventory consists of eight questions, each reflecting a different self reported dimension of tinnitus associated problems. The dimensions covered largely reflect those categories determined by the open questions in the Tyler and Baker study (20) and include the perceived effect of tinnitus on hearing, health, sleep, peace of mind, other people, activities, enjoyment of life as well as the sense of annoyance generated by the tinnitus. The inventory is presented on a single page. Each question is phrased simply, based on the format of the IOI-HA and has five response choices ranging from the least favourable to most favourable impact. All items are scored in the same direction. Each item is scored from 1 to 5, with 1 indicating great difficulty with tinnitus and 5 indicating no difficulty. Low scores, therefore, reflect a more intrusive perception of tinnitus. The inventory was translated into French with the translations checked by back translation and modified where necessary. The English and French versions are shown as Appendices 1 and 2, respectively. Data analysis The distribution and inter-relationships of the different items were analysed. Since the Kolmogorov-Smirnov normality test revealed a non-normal distribution of the inventory scores for some of the individual items, rank order correlation coefficients were calculated to assess inter-item correlations. The overall internal consistency between individual items in the inventory was then assessed computing Cronbach s alpha. A factor analysis

5 Development of the International Tinnitus Inventory 231 Table 2. Responses from the Cardiff patients for the different items of the International Tinnitus Inventory Inventory items Annoyance Hearing Health Sleep Peace Others Activities Enjoyment Valid responses Missing responses No. reporting total ITI score Total ITI score (each of the 8 items scored 1-5) Fig. 2. ITI Total scores (Lyon and Cardiff data). Lyon Cardiff with principal components was performed to explain the variance in the individual scores. Finally, a multiple regression analysis was performed to assess the influence of demographic variables (age, gender), duration of tinnitus, hearing status, family history of tinnitus, and family history of hearing loss on the total inventory score. RESULTS Response rates for each ITI item The scores of the inventory items were calculated showing an overall response rate for each item. The inventory was well completed with few responses omitted from patients in Cardiff (Table 2) while all items were completed for the 300 patients in Lyon. Frequency distribution of ITI scores Descriptive statistics including frequency distribution, median overall scores and the median score for each of the eight ITI items were obtained. The frequency distribution for the overall total scores is shown in Figure 2 for both the Cardiff and Lyon data. The median scores for each of the individual items and the total inventory score for the Cardiff and Lyon data are shown in Figure 3. The annoyance caused by the tinnitus and its intrusion into enjoyment of life were the predominant adverse complaints in Cardiff patients. For Lyon subjects, the worst median scores corresponded to annoyance caused by tinnitus and its perceived intrusion into peace of mind. Internal consistency of ITI Inter-item correlations and individual-total item correlations are shown in Table 3. All the items of the inventory Annoyance Hearing Health Sleep Peace Others Activities Enjoyment Total Fig. 3. Median total ITI scores for Cardiff and Lyon. Lyon Cardiff were shown to significantly correlate with each other both in Cardiff and in Lyon. All these correlations were positive. High Cronbach s alpha coefficients also demonstrated the excellent internal consistency of the English and French versions of the ITI, with values of 0.91 and 0.87, respectively. Moreover, the Cronbach s alpha coefficient decreased after removing each of the eight ITI items from the construct. This also reflects a high inter-item correlation and suggests that each item importantly contributes to ITI outcomes. The factor analyses performed on the data from each of the two centres showed that only one factor exhibited an eigen value higher than 1 and accounted for more than 50% of the total variance (64% for the Cardiff population and 54% for the Lyon population). All eight items of the inventory contributed a similar degree of loading. Consequently, they were all necessary for assessment of tinnitus impact as measured by the ITI. Effect of demographic variables, tinnitus duration, hearing status and family history on ITI outcomes The items of the inventory, as well as the total inventory score, were compared with the age of the individual, gender, tinnitus duration, hearing status and family history. In the Cardiff sample we also compared the data against whether the patient was a new or follow-up patient at the tinnitus clinic and against the hearing thresholds of the individuals to see if there was any correlation between these factors and the inventory items. For the Lyon data, family history was rated between 0 (without family history) and 3 (family history of tinnitus and hearing loss)

6 232 V Kennedy et al. Table 3. Kendall s tau correlations between inventory items Item 1 Annoyance Item 2 Hearing impact Item 3 Health Item 4 Sleep Item 5 Peace of mind Item 6 Others Item 7 Activities Item 8 Enjoyment Total Items Score Item Item Item Item Item Item Item Item The upper figures represent the Cardiff data (p < 0.001), the lower figures in italics the Lyon data (bold italic numerals indicate p < and non-bold p < 0.002). with 1 (family history of hearing loss only) and 2 (family history of tinnitus only). The results of this comparison are shown in Table 4a (Cardiff) and 4b (Lyon). Cardiff data Kendall s tau correlations showed a significant negative correlation (tau = 0.23; p < 0.01) between the total inventory score and hearing level, particularly the worse ear hearing level, indicating a worsening impact of tinnitus with increased hearing difficulty. This correlation was significant for most of the individual inventory items. There was a lesser negative correlation (tau = 0.15; p < 0.05) between the total inventory score and tinnitus duration. A significant positive correlation was noted between the annoyance item of the inventory and the patient s year of birth (tau = 0.21; p < 0.01) but no significant correlation between this and the overall inventory score. Furthermore, there were no significant correlations between the other demographic factors and either the individual items or the total inventory score. Thus, there was no significant relationship between the inventory items (individual or total) and gender, whether the patient was a new or follow-up attender at the clinic, or whether the individual reported a family history of tinnitus or hearing impairment. Lyon data A negative correlation was found between the total score and the severity of the difficulty hearing TV (tau = 0.10; p < 0.01). Item 2 score ( hearing impact ) was the only item to be significantly correlated with this severity (tau = 0.35; p < 0.005). A significant negative correlation was also observed between item 2 score and tinnitus duration (tau = 0.09; p < 0.005). Scores on the items 4 ( sleep ; tau = 0.13; p < 0.005) and 5 ( peace of mind ; tau = 0.12; p < 0.005) were correlated with the patient s age. Item 3 score ( health ) was significantly correlated (tau = 0.10; p < 0.05) with the fact of having a family history. No correlation was pointed out between total score or any individual item and gender. Overall, it was noted that in both samples (Cardiff and Lyon), deterioration in hearing showed the most significant relationship with the total ITI score reflecting a worsening perception of tinnitus. However, none of the correlations found in these analyses, while significant, was greater than 0.27, thus accounting for only a small part of the total variance. DISCUSSION Tinnitus is a common complaint but its impact can vary. Not only does it affect different individuals to varying degrees, but the primary complaint(s) attributed to tinnitus may vary. Some of the reported difficulties may be inter-related, e.g. the perceived tinnitus effect on life style and emotional state. It is difficult to effectively direct therapy or evaluate therapy if the primary complaint(s) has not been identified. Any counselling or cognitive behavioural therapy approach needs to address the problems attributed to tinnitus which are specific to the individual complaining of it. The International Tinnitus Inventory (ITI) is a measure which has been designed to

7 Development of the International Tinnitus Inventory 233 Table 4. Kendall s tau correlations re demographics and inventory items a: Cardiff patients Item 1 Annoyance Item 2 Hearing impact Item 3 Health Item 4 Sleep Item 5 Peace of mind Item 6 Others Item 7 Activities Item 8 Enjoyment Total Items Score Family History NS NS NS NS NS NS NS NS NS Year of Birth 0.21** NS NS NS NS NS NS NS NS Gender NS NS NS NS NS NS NS NS NS Tinnitus Duration 0.15* 0.17** NS NS NS NS 0.21** 0.17** 0.15* BEHL 0.15* 0.22** NS NS NS 0.16* 0.14* NS 0.17** WEHL 0.16* 0.27** 0.16* NS 0.14* 0.24** 0.19** 0.18** 0.23** New /Follow up NS 0.16* NS NS NS NS NS NS NS BEHL: Better Ear Hearing Level. WEHL: Worse Ear Hearing Level. NS: not significant; *p < 0.05, **p < 0.01 (two-tailed). b: Lyon subjects Item 1 Annoyance Item 2 Hearing impact Item 3 Health Item 4 Sleep Item 5 Peace of mind Item 6 Others Item 7 Activities Item 8 Enjoyment Total Items Score Family History NS NS 0.10* NS NS NS NS NS NS Age NS NS NS 0.13*** 0.12*** NS NS NS NS Gender NS NS NS NS NS NS NS NS NS Tinnitus Duration NS 0.09* NS NS NS NS NS NS NS Severity of the difficulty hearing TV NS 0.35*** NS NS NS NS NS NS 0.10* NS: not significant; *p < 0.05, ***p <

8 234 V Kennedy et al. reflect the most commonly reported complaints associated with tinnitus. These include a sense of annoyance caused by the presence of the tinnitus, disturbance of peace of mind, perceived impingement of tinnitus on enjoyment of life and perceived effect of tinnitus on hearing, health, sleep, other people, and general activities. The ITI provides an overview of the complaints of the individual with tinnitus, and all these complaint items to have been shown to correlate well with each other for both the Cardiff patients and Lyon subjects. Within the inventory the highest correlation (tau = 0.68) within the Cardiff population was between annoyance and peace of mind and the lowest (tau = 0.32) was between annoyance and health effects, while within the Lyon sample they were respectively between activities (item 7) and enjoyment (item 8) (tau = 0.71) and between hearing impact (item 2) and sleep (item 4) (tau = 0.17). We also looked at possible correlations between the demographics of the patient (age, hearing level, family history of tinnitus and/or hearing impairment) and the inventory items, individually and total score. The main correlation identified was with hearing level, particularly the worse ear hearing level for the Cardiff patients (tau = 0.23) and the difficulty hearing TV for the Lyon subjects (tau = 0.10). In the Cardiff patients, tinnitus duration correlated significantly with half of the individual inventory items as well as with the total inventory score. In Lyon subjects it correlated only weakly (tau = 0.09) with hearing impact. Discrepancies observed between the two samples could be explained by their difference in size, the number of Lyon subjects being about twice that of the Cardiff patients and also by differences in subject selection, the Cardiff group having been recruited from a tinnitus clinic and the Lyons group from the meetings or website of a tinnitus association. Administration of a questionnaire via the internet may be associated with scores other than might be expected using paper-based methods. Andersson et al. (24) noted higher anxiety scores in people with tinnitus on an internet administered questionnaire than those noted in a clinic population. While this difference may have been related to the internet administration of the questionnaire, it was more likely to be related to the self selection by individuals seeking the psychological intervention offered. The differences in the two sites in this study may, therefore, also reflect the characteristics of a self recruiting population rather than cultural differences. While no questionnaire can replace the quality of information obtained from a detailed history, clinically the inventory can help highlight the main complaints attributed to tinnitus as well as provide an overview of the relative prominence of the impact on different aspects of an individual s life and sense of well-being. It may be used as a screening instrument. In highlighting the predominant complaints, the ITI may help the clinician choose the most appropriate outcome measure or most effective rehabilitation approach. It can help with resource planning, supporting the need of a particular service, e.g. hearing therapist, psychologist or sleep interventions, within the tinnitus service. The ITI can also be incorporated into studies to complement outcome measures aimed at a specific aspect of tinnitus. These features make the inventory a useful tool for standardizing or providing comparability across studies, as not only can studies be compared across different languages but it allows groups of individuals complaining of similar tinnitus-related problems to be compared. While there can be problems basing a questionnaire on the results of open ended questions, particularly in how the data are analysed and coded, both of the cited studies (20, 21) looking at the tinnitus related problems volunteered by patients using open-ended questions reported comparable domains. Because of the single factor nature and good internal consistency of the International Tinnitus Inventory using these domains, we feel that the International Tinnitus Inventory is a useful measure of tinnitus. It has the benefit of being brief with a simple response format. It has been shown to have a good response rate, high internal consistency and is easy to interpret. Preliminary results indicate that the ITI also translates well. It is encouraging to note that the data from both the English and French versions showed similar results: high Cronbach s alpha coefficients and item-total correlations were found. Also only one factor appeared to explain the pattern of correlations within the set of inventory items in both studies. As with any tinnitus measure, the International Tinnitus Inventory does not reflect the intermittent and changing nature of tinnitus. In adhering to the format of the IOI-HA we used a two-week time period to provide a snapshot of the tinnitus. A further study is intended in which the International Tinnitus Inventory is used in the same individuals over a period of time to test its reliability over time and the response to treatment. In summary, the International Tinnitus Inventory can be a useful measure in clinical practice. It reflects the distribution of the commonest patient-reported problems and is short and user-friendly. This measure can be easily incorporated into other studies to give some idea of the comparability of the population under consideration. Because of its brief and unambiguous format, it can act as a model for comparison across studies, different clinical service models as well as different national models to explore the diverse nature of tinnitus. It can also act as a guide towards selecting the most useful assessment methods, treatment plan and outcome measure for a particular individual or to supplement one looking

9 Development of the International Tinnitus Inventory 235 primarily at a particular aspect of tinnitus, e.g. psychosocial effects or perceived severity. ACKNOWLEDGEMENTS This paper has been published with the support of the European Commission, Fifth Framework Programme, Quality of Life and Management of Living Resources programme. The authors are solely responsible for this publication. It does not represent the opinion of the Community. The Community is not responsible for any use that might be made of data appearing therein. The authors thank Gabriela Ciuperca from Institut Camille Jordan, Université Claude Bernard Lyon for her invaluable help in analysing the data. REFERENCES 1. Davis A. Hearing in adults. London: Whurr; Skarzynski H, Rogowski M, Bartnik G, Fabijanska A. Organization of tinnitus management in Poland. Acta Otolaryngol 2000; 120: Hazell JWP, McKinney CJ, Alesky W. Mechanisms of tinnitus in profound tinnitus. Ann Otol Rhinol Laryngol 1995; 166 (Suppl): Dineen R, Doyle J, Bench J. Managing tinnitus: a comparison of different approaches to tinnitus management training. Br J Audiol 1997; 31: Hiller W, Janca A, Burke KC. Association between tinnitus andsomatoformdisorders. JPsychosomRes1997; 43: Rubinstein B, Axelsson A, Carlsson GE. Prevalence of signs and symptoms of craniomandibular disorders in tinnitus patients. J Craniomandib Disord Facial Oral Pain 1990; 4: Stephens SDG, Hallam RS. The Crown-Crisp experimental index in patients complaining of tinnitus. Br J Audiology 1985; 19: Hiller W, Goebel G. Comorbidity of psychological disorders in patients with complex chronic tinnitus. In: Goebel G, editor Tinnitus Psychosomatic Aspects of Complex Chronic Tinnitus. London: Quintessence Publishing Co Ltd; p Noble W. Self-reports about tinnitus and about cochlear implants. Ear Hear 2000; 21(Suppl): S Hallam RS, Jakes SC, Hincliffe R. Cognitive variables in tinnitus annoyance. Br J Clin Psychol 1988; 27: Hiller W, Goebel G. A psychometric study of complaints in chronic tinnitus. J Psychosom Res 1992; 36: Kuk FK, Tyler RS, Russell D, Jordan H. The psychometric properties of a tinnitus handicap questionnaire. Ear Hear 1990; 11: / 13. Halford JBS, Anderson SD. Tinnitus severity measured by a subjective scale, audiometry and clinical judgement. J Laryngol Otol 1991; 105: Wilson PH, Henry J, Bowen LM, Haralambous G. Tinnitus Reaction Questionnaire: Psychometric properties of a measure of distress associated with tinnitus. J Speech Hear Res 1991; 34: Newman CW, Jacobson GP, Spitzer JB. Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg 1996; 122: Erlandsson SI, Hallberg LRM, Axelsson A. Psychological and audiological correlates of perceived tinnitus severity. Audiology 1992; 31: Kennedy V, Wilson C, Stephens D. Quality of life and tinnitus. Audiol Med 2004; 2: Hiller W, Goebel G. Rapid assessment of tinnitus-related psychological distress using the Mini-TQ. Intern J Audiol 2004; 43: Stephens D, Lewis P, Davis A. The influence of a perceived family history of hearing difficulties in an epidemiological study of hearing problems. Audiol Med 2003; 1: Tyler R, Baker L. Difficulties experienced by tinnitus sufferers. J Speech Hear Disord 1983; 48: Sanchez L, Stephens D. A tinnitus problem questionnaire in a clinic population. Ear Hear 1997; 18: Cox R, Hyde M, Gatehouse S, Noble W, Dillon H, Bentler R, et al. Optimal outcome measures, research priorities and international cooperation. Ear Hear 2000; 21: S Cox RM, Alexander GC. The International Outcome Inventory for Hearing Aids (IOI-HA): psychometric properties of the English version. Int J Audiol 2002; 41: Andersson G, Kaldo-Sandström V, Ström L, Strömgren T. Internet administration of the Hospital Anxiety and Depression Scale in a sample of tinnitus patients. J Psychosom Res 2003; 55: Address for correspondence: Veronica Kennedy Welsh Hearing Institute University Hospital of Wales Heath Park Cardiff Wales CF14 4XW vkennedy@doctors.org.uk

10 236 V Kennedy et al. APPENDIX 1. INTERNATIONAL TINNITUS INVENTORY ENGLISH VERSION 1. Think about your tinnitus over the past two weeks. On an average day, how often have you found it annoying? all the time most of the time some of the time occasionally never 2. Think about the situation where you most wanted to hear. Over the past two weeks, how much difficulty has the tinnitus caused in that situation? very much difficulty quite a lot of difficulty moderate difficulty slight difficulty no difficulty 3. How much has your tinnitus caused or aggravated other health problems? very much quite a lot moderately slightly not at all 4. Over the past two weeks, how much has your tinnitus affected your sleep? very much quite a lot moderately slightly not at all 5. Over the past two weeks, how much has your tinnitus affected your peace of mind? very much quite a lot moderately slightly not at all 6. Over the past two weeks, how much do you think your tinnitus has affected other people? very much quite a lot moderately slightly not at all 7. Overall, how much has your tinnitus affected the things you can do? very much quite a lot moderately slightly not at all 8. Considering everything, how much has your tinnitus changed your enjoyment of life? very much worse quite a lot worse slightly worse not at all better APPENDIX 2: INTERNATIONAL TINNITUS INVENTORY FRENCH VERSION 1. Si vous pensez à vos acouphènes durant ces 2 dernières semaines, combien de temps par jour êtes vous gêné(e) par vos acouphènes? tout le temps la plupart assez souvent parfois jamais du temps 2. Pensez à la situation dans laquelle il est pour vous le plus important d entendre. Durant les 2 dernières semaines, quelle difficulté avez-vous ressenti dans cette situation à cause de vos acouphènes? beaucoup de difficulté pas mal de difficulté difficulté moyenne légère aucune

11 3. Pensez vous que vos acouphènes ont causé ou aggravé d autres problèmes de santé? Beaucoup assez moyennement un peu pas du tout 4. Durant les 2 dernières semaines, est-ce que vos acouphènes ont perturbé votre sommeil? Beaucoup assez moyennement un peu pas du tout 5. Durant les 2 dernières semaines, dans quelle mesure vos acouphènes ont-ils altéré votre tranquillité d esprit? Beaucoup assez moyennement un peu pas du tout 6. Durant les 2 dernières semaines, pensez vous que vos acouphènes ont perturbé votre entourage? Beaucoup assez moyennement un peu pas du tout 7. De façon générale, quel est l impact de vos acouphènes sur vos activités quotidiennes? très important assez important moyennement important peu important pas important du tout 8. Tout bien considéré, dans quelle mesure vos acouphènes ont-ils affecté votre plaisir de vivre? de façon très importante de façon assez importante Development of the International Tinnitus Inventory 237 moyennement Peu pas du tout

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