Systematic review of evidence on the association between personality and tinnitus

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Brazilian

Journal

of

OTORHINOLARYNGOLOGY

www.bjorl.org

REVIEW

ARTICLE

Systematic

review

of

evidence

on

the

association

between

personality

and

tinnitus

夽

,

夽夽

Samantha

Mucci

a,∗

,

Luciana

Geocze

a

,

Denise

Caluta

Abranches

a

,

Andrés

Eduardo

Aguirre

Antúnez

b

_,

_Norma

_de

_Oliveira

_Penido

c

a_Department_of_Psychiatry,_Escola_Paulista_de_Medicina,_Universidade_Federal_de_São_Paulo_{(UNIFESP-EPM),}_São_Paulo,_SP,_Brazil b_Instituto_de_Psicologia_da_Universidade_de_São_Paulo_(USP),_São_Paulo,_SP,_Brazil

c_Department_of_{Otorhinolaryngology}_and_Head_and_Neck_Surgery,_Escola_Paulista_de_Medicina,_Universidade_Federal_de_São_Paulo

(UNIFESP-EPM),SãoPaulo,SP,Brazil

Received5August2013;accepted7November2013 Availableonline4July2014

KEYWORDS Personality; Tinnitus; MMPI; Review

Abstract

Introduction:Thescientificliteraturedemonstratesthatpersonalitytraitsareassociatedwith

theindividual’sadaptationtochronicdiseases,andcanbeanimportantfactorintheetiology

andprognosisofphysicalillness.Some studiesindicatethatpersonalitycharacteristicsmay

influencetheperceptionoftinnitus.

Objective: Toassessthescientificevidenceoftheassociationbetweentinnitusandpersonality.

Methods:A systematicreviewofthefollowingdatabases:PubMed,SciELO,LILACS,andWeb

ofKnowledge.Onlystudiesofpatientsolderthan18yearspublishedinEnglish,Portuguese,or

Spanishthatestablishedanassociationbetweentinnitusandpersonalitywereselected.

Results:Seventeenofthe77articlesfoundwereselected:13cross-sectionalstudies,two

lon-gitudinalstudies,onevalidationstudy,andonebirthcohortstudy.Thesamplesrangedfrom27

to970patients.

Conclusion: Some personality traits, especially neuroticism, psychasthenia, and schizoid

aspects,maybeassociatedwithtinnitusperceptionandwiththeannoyanceduetothis

symp-tom.

ElsevierEditoraLtda.Allrightsreserved.

夽 _Please_cite_this_article_as:_Mucci_S,_Geocze_L,_Abranches_DC,_Antúnez_AE,_Penido_NO._Systematic_review_of_evidence_on_the_association

betweenpersonalityandtinnitus.BrazJOtorhinolaryngol.2014;80:441---7.

夽夽

Institution:DepartmentofOtorhinolaryngologyandHeadandNeckSurgery,UniversidadeFederaldeSão Paulo(UNIFESP-EPM),São Paulo,SP,Brazil.

∗_{Corresponding}_author.

E-mail:sammucci@gmail.com(S.Mucci). http://dx.doi.org/10.1016/j.bjorl.2014.05.031

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PALAVRAS-CHAVE Personalidade; Zumbido; MMPI; Revisão

Revisãosistemáticasobreasevidênciasdaassociac¸ãoentrepersonalidadeezumbido

Resumo

Introduc¸ão:Sabe-se,naliteraturacientífica,quecaracterísticasdepersonalidadeestão

associ-adasàadaptac¸ãodoindivíduoadoenc¸ascrônicas,tornando-seumfatorimportantenaetiologia

eprognósticodedoenc¸asfísicas.Algunsestudosapontamquecaracterísticasdepersonalidade

podeminfluenciarnapercepc¸ãodozumbido.

Objetivo:Verificarasevidênciascientíficasdaassociac¸ãoentrezumbidoepersonalidade.

Método: Estudoderevisãosistemáticanasseguintesbasesdedados: Pubmed,Scielo,Lilacs

e Web of knowledge. Foram selecionados apenas os estudos com pacientesmaiores de 18

anos,publicadoseminglês,portuguêsouespanholequeestabeleceramumaassociac¸ãoentre

zumbidoepersonalidade.

Resultados: Dos77artigosencontrados,17foramselecionados:13estudostransversais,dois

estudoslongitudinais,umestudodevalidac¸ãoeumestudodecoortedenascimento.Asamostras

variaramde27a970pacientes.

Conclusão:Algumascaracterísticasdepersonalidade,especialmenteneuroticismo,psicastenia

easpectosesquizoides,podemestarassociadosàpercepc¸ãoeaoincômododozumbido.

ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Tinnitus is defined as a perception of sound in the absence of an external sound source.1,2 _It _is _a

symp-tom that may be related to a number of biological, pharmacological,nutritional,and psychologicaletiologies, and most often multiple etiologic factors are involved.3

Pavan4 _reported _that _{approximately} _20% _of _the

gen-eral population suffers from some form of tinnitus. Other studies have reported incidences of 10---32% of the population.1,5

Inmost cases,tinnitusis asymptom perceived onlyby thepatient,anditisnotpossibletomeasureitobjectively. Thediscomfortfromtinnitusissubjectiveandvariablewith respect to intensity and frequency, and can significantly impactthepatient’s lifeandcauseadversepersonal, pro-fessional,social,andfamilyconsequences.Twentypercent ofpatientswithchronictinnitusreportittobesevereand disabling.1,6

Tinnitusisasymptomthathasphysicalandpsychological dimensionsandacomprehensive approachrequiresa mul-tidisciplinaryteamtoprovide appropriateassessmentand treatmentfortheaffectedpatients.7,8

Manyresearcherssuggest that psychological character-istics may be related to the impact of tinnitus on the lives of patients. Patients with severe tinnitus may have hystericaldefenses,depressiveand/or anxietysymptoms, stress, irritability, difficulty concentrating and sleeping, negative effects in mood, and impairment in performing dailyactivities.7---11

Personality can be defined asan aggregate of charac-teristics that distinguish one individual from all others. Some theorists consider that personality is the essence of the human condition.12 _Personality _involves _the

total-ity of psychic dynamics, and its formation evolves from theinteractionofgenetic,physiological,emotional, cogni-tive,social,andculturalfactors.Itisthepersonalitythat

determinesthinking,attitudes,beliefs,thewayof perceiv-ing the world and relating to other people, and it also hasan impactonhealthand diseaseprocesses.13,14 _In _the

realm of personality, conscious and unconscious aspects, behaviors, affective-emotional experiences, intrapsychic conflicts, thoughts, and feelings are all considered. The structureofpersonalityisrelativelystableandpredictable, andthedynamicsofpersonalitydeterminehowthe individ-ualrelatestotheenvironment.

The assessment of personality can be conducted by mentalhealthprofessionalsbymeansofstructuredor semi-structuredclinical interviews based onDSM-IV-TR,15 _or _by

psychologists using psychological assessment instruments. Thereareavarietyofpsychologicalassessmentinstruments abletoassesspersonalitystructureanddynamics;thesecan beobjectiveinstruments(evenself-administered)or projec-tiveexpressivemethods.16,17 _The _use_of_these_instruments

isrestrictedtopsychologists.18,19

Inthescientificliterature,therearemanyarticles study-ing the association of personality to health and disease process.Thearticlesdescribethecharacteristicsof person-ality asan important factor in theetiology and prognosis of physicalillnesses whenassociatedwithother factors.20

Welch andDawes21 _comment _that_personality

characteris-ticsmayinfluencetheperceptionoftinnitus.Thereisscant literatureregardingstudiesof thepersonality characteris-ticsoftinnituspatients.Todate,noresearchonthesubject hasbeenpublishedinBrazil.

Theobjective ofthis studywastoassess the scientific evidenceoftheassociationbetweentinnitusand personal-ity.

Method

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TheinclusioncriteriawerestudiespublishedinEnglish, Portuguese,or Spanishuntil2013 withpatientsolder than 18 yearsthat established an association between tinnitus andpersonality.Studiesthatcorrelatedsymptomsofanxiety and/ordepressivesymptomswithtinnitus,studieson per-sonalitycharacteristicsinpatientswithdizzinessorchronic disease,letterstotheeditor,andtheoreticalstudieswere excluded.

In the search strategy for PubMed, descriptors of the MedicalSubjectHeadings(MeSHterms)wereusedandthe strategychosen wasasfollows:Tinnitus [Mesh]AND ( Per-sonality [Mesh]OR Personality Disorders [Mesh]OR MMPI

[Mesh])AND(English[lang]ORSpanish[lang]ORPortuguese

[lang])ANDadult[MeSHTerms].

In the Web of Knowledge database, the strategy was (TS=(personality) AND TS=(Tinnitus)) AND Lan-guage=(EnglishORPortugueseORSpanish)ANDDocument Types=(ArticleORReview)Databases=SCI-EXPANDED,SSCI, A&HCI,CPCI-S,CPCI-SSHTimespan=Allyears.

IntheSciELOandLILACSdatabases,indexeddescriptors in theHealthSciences Descriptors Headings (MeSHterms) were used, and the following strategy was implemented:

tinnitusANDpersonalityORpersonalitydeterminationOR

personality disorders ORpersonality tests OR MMPI (Min-nesotaMultiphasicPersonalityInventory).

Results

Accesstothearticleswasperformedbyonlinedistribution viatheCAPESPortal;andbytheattendanceofresearchers to BIREME to access printed journals and purchase items fromthepublichealthlibrary.

In all, 43 studies in PubMed and 45 studies in Webof Knowledgewere found; 11 articleswere commontoboth databases.NostudieswerefoundintheLILACSandSciELO databases.Intotal,77articleswerecollectedfortheperiod 1968---2012.

The selection of papers to be included in the review was performed by two reviewers after reading the 77 articles; 1721---37 _articles _that _met _the _inclusion _criteria

were selected, and 60 articles were excluded. Articles wereexcludedbecausetheydidnotpresentanassociation betweenpersonalityandtinnitus.Mostofthemassociated psychopathologicalsymptoms(suchasanxietyand depres-sion)totinnitus.Tenarticleswereexcludedbecausethey studied an association among personalityor psychological characteristics and non-otologic chronic diseases or oto-logicdiseasesexcepttinnitus;andonearticlewasexcluded becauseitwasatheoreticalstudy,notdealingwithscientific research(Fig.1).

Tworeviewers tabulateddataofselectedarticlesusing the following information: authors, year of publication, studytype,samplesize,instrumentsforpersonality assess-ment used, and main results of the association between tinnitusandpersonality(Table1).

The 17 selected articles included 13 cross-sectional studies,22---24,26---30,32,33,35---37 _two _prospective

longitudi-nal studies,25,34 _one _validation _study,31 _and _one _birth

cohort study.21 _These _studies21---37 _demonstrate _that

there are associations between some personality char-acteristics and tinnitus perception and the annoyance

77 Articles found

PubMed = 43 Web of knowledge

= 45 SciELO = 0

Repeated articles = 11

Excluded after reading the article

= 60

Articles selected after reading = 17

LILACS = 0

Figure1 Results.

caused by this symptom. The samples ranged from27 to 970patients.

Studies have demonstrated that there is a pre-dominance of certain personality characteristics in patients with tinnitus, such as neuroticism22,24,27---31,34,35,37

(neurotic triad: hysteria,22,27,33 _{hypochondria,}23,33 _and

depression),23,25---27,32,35---37_{psychasthenia,}25,26,33_and_schizoid

features.22,25,33,34

Neuroticisminvolvesa broadrangeofnegative person-alitycharacteristics due to the presence of psychological distress, anxiety, and behavioral cognitive impairment.38

The affected subjects are anxious, prone to emotional instability and mood swings, and have a tendency to self-deprecation and exaggerated concerns, especially in relationtobodyandhealth,whotendtooverreacttomany differenttypesofstimuliandtointerpret situationsmore seriouslythantheyare;theyarelikelytoexhibitphysical symptoms with no organic etiology, devitalization, and a tendencytowarddepression.13,38

Psychastheniaisassociatedwiththepresenceofintense anxietyandasignificantnervousbreakdown.Psychasthenic peopleexhibitimpulsive,obsessive,andphobictendencies, mentalruminationbehavior,psychomotoragitation,diffuse orsystematic fear,anxiety associatedwithphysical symp-toms,andatendencytoexperiencedistressingfeelings.13,39

Individuals with a high score of schizophrenia refer to thepresenceofschizoidaspectsoftheirpersonality.They aresolitarypeoplewithemotionalvulnerability,whoavoid socialcontact,feel threatenedand persecuted,and have difficultydistinguishingfantasyfromreality,haveanaffinity forstrangeandunusualthings,andatendencytohostility andwickedness.13

Themostwidelyusedinstrumentforassessing personal-itytraitsistheMinnesotaMultiphasicPersonalityInventory (MMPI)22---26,29,32_(seven_studies);_this_is_a_{psychological} _test

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Table1 Descriptionofpapersshowinganassociationbetweenpersonalityandtinnitusregardingtheinstrumentsused.

Authorsandyear Studytype Sample Personalityassessment

instruments

Majoroutcomesassociated

withtinnituspatientsand

conclusion

ReichGEandJonhsonRM,

1984.

Transversal 146 MMPI168(Minnesota

MultiphasicPersonality

Inventory---168short

version)

Highscoresofneuroticism

(hysteria,hypochondria,and

depression)andinthescalesof

schizophreniaandparanoia.

GerberK,NehemkisAM,

CharterRA,JonesHC,

1985---1986.

Transversal 45 MinnesotaMultiphasic

PersonalityInventory

(MMPI)

Pathologicallevelsinthe

scalesofhypochondriaand

depression.

O’ConnorS,HawthorneMR,

BrittenSR,WebberP,

1987.

Transversal 105 EysenckPersonality

Questionnaire(EPQ)

9.5%hadhighneuroticism

scores,butnosignificant

correlationwithseveretinnitus

annoyance.

ColletL,MoussuMF,

DubreuilC,DisantF,

AhamiT,ChanalJM,

MorgonA,1987.

Longitudinal prospective

27 MMPI Therewerestatistically

significantdifferences

associatedtoscalesof

depression,schizophrenia,and

psychasthenia.

ColletL,MoussuMF,Disant

F,AhamiT,MorgonA,

1990.

Transversal 100 MMPI Menshowedhighlevelsonthe

depressionscale.

Psychastheniaisassociated

withhearingloss,and

hypochondriaisassociated

withalongsymptomatic

period.

MckeeGJ,StephensSDG,

1992.

Transversal 37 Crown-CrispExperiential

Index

Highscoresofneuroticism.

RussoJ,KatonW,Sullivan

M,ClarkM,BuchwaldD,

1994.

Transversal 224 StructuredPsychiatric

DiagnosticInterview

Schedulebasedon

DSM-III-R;Cloninger’s

Tridimensional Personality.

Higherscoresofpessimism,

worry,impulsivity,neuroticism,

andnegativeaffectivity.

MericC,GartnerM,Collet

L,

Chéry-CrozeS,1998.

Transversal 281 MMPI Scoresofneuroticismstandout

RutterDR,SteinMJ,1999. Transversal 248 EPQ Higherscoresforneuroticism,

butnotstatisticallysignificant

whencomparedtopatients

withchronicdiseases.

ZachariaeR,MirzF,

JohansenLY,AndersenSE,

BjerringP,PedersenCB,

2000.

Validation 50 EPQ Highscoresofneuroticism.

VallianatouNG,

ChristodoulouP,Nestoros

JN,HelidonisE,2001.

Transversal 80 MMPI Scoreswithinaverage.Onlythe

depressionscalewashigher.

BayarN,OguztürkO,Koc¸C,

2002.

Transversal 56 MMPI Highscoresonpsychasthenia

scale.Womenalsohadhigher

scoresonhypochondria,

hysteria,schizophrenia,and

socialintroversionscales.

LagenbachM,OlderogM,

MichelO,AlbusC,Köhle

K,2005.

48 SymptomChecklist

90-Revised(SCL-90-R),

Freibürger

Persönlichkeitsinventar (FPI-R)

Statisticallysignificant

differencesinscoresof

somatization,anxiety,and

somaticcomplaints;and

psychoticism,excitability,and

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Table1(Continued)

Authorsandyear Studytype Sample Personalityassessment

instruments

Majoroutcomesassociated

withtinnituspatientsand

conclusion

LangguthB,KleinjungT,

FischerB,HajakG,

EichhammerP,SandPG,

2007.

Transversal 72 NEO-FiveFactor

Inventory(NEO-FFI),

Thetraitsofanxietyand

neuroticismareassociated

withthepresenceof

depressivesymptomsandthe

severityoftinnitus.

WelshD,DawesPJD,2008. Cohort

970 MPQ(Multidimensional

Personality Questionnaire)

Personalitytraitsmaybe

associatedwithtinnitus.

BartelsH,PedersenSS,Van

derLaanBF,StaalMJ,

AlbersFW,MiddelB,

2010.

Transversal 265 DS-14(TypeDScale-14) Theprevalenceofpatients

withapessimisticpersonality

(typeDpersonality)was35.5%.

BartelsH,MiddelB,

PedersenSS,StaalMJ,

AlbersFWJ,2010.

Transversal 530 EPQ,DS-14,

FFPI(Five-Factor

PersonalityInventory).

Thepersonalitytraitsof

neuroticismandpessimism

(typeD)areprevalentin

patientswithtinnitus.

instruments used were as follows: Eysenck Personality Questionnaire24,30,31,37_(EPQ,_four_studies),_Type_D_Scale36,37

(twostudies),StructuredPsychiatricDiagnosticInterview28

(one study), NEO Five-Factor Inventory35 _(one _study),

Five-Factor Personality Inventory 37 (one study), Multidi-mensional Personality Questionnaire21 _(MPQ, _one _study),

Freibürger Persönlichkeitsinventar34 _(one _study),

Crown-Crisp Experiential Index27 _(one _study), _and _{Cloninger’s}

Tridimensional Personality Questionnaire28 _(one _study),

associating audiological and otological assessments with detailedquestionnairesabouttinnitus.

Discussion

The majority of studies selected were cross-sectional.22---24,26---30,32,33,35---37 _{Cross-sectional} _and _validation

studies cannot establish predictive relationships between personality characteristics found in groups of tinnitus patients;however,theywereabletodetectthatthegroups ofpatientswithtinnituspresentmorepersonalitydisorders suchas neuroticism,psychasthenia, and schizoid features thanthegeneralpopulation.21---37_These_{characteristics}_may

influencepatients’perceptionoftinnitus,theirdiscomfort, and the meaning that they assign to this annoyance, therebymakingitdifficulttolivewithchronictinnitusand worseningitsimpactontheirlives.

Allindividualsareexposedtothedemandsandpressures imposedbytheeventsofordinarylifeand,tocopewith anxi-etyandconcerns,utilizetheiremotionalresources.Patients withtinnitushavefewerresourcestocopewithanxietyand affectivedistress,andtendtoexperiencetheirdistressing emotionsmore intensely.These patients have a personal-itystructurelessadaptedandmoresusceptibletophysical manifestationsoftheirsuffering,andanexacerbated con-cernabout thebodyandthediscomfortoftinnitus.These characteristicsmaybeassociatedwiththefactthat tinni-tuscancausethepatienttosufferemotionaloverloadand intenseanxiety,justasoccursinotherchronicdiseases.

The mostrelevantretrievedstudies weretwo prospec-tivelongitudinalstudies25,34_and_one_study_of_birth_cohort.21

Studies indicate some personality characteristics as pre-dictorsof increasedsuffering oftinnitus andpoorpatient compliancetotheirsymptoms,definingtheimpactof tinni-tusintheirlife,itsseverity,andannoyance.21,25,34_Patients

who report severe annoyance with tinnitus have specific personality traits and psychopathological symptoms that combinetolowerthepatients’satisfactionwiththeirlife and hinder their adaptation to chronic tinnitus.25,34 _The

cohort study of Welsh and Dawes,21 _with ₉₇₀ _patients,

assessed the personality characteristics of patients at 32 yearsof age,and found an association amongpersonality characteristicsandthepresenceoftinnitus.Thesedata sug-gestthatthetreatmentforthesepatientsmustrelyonthe helpof mental health professionals, alleviating their psy-chologicaldistress,theanxiety,andemotional,social,and relationalinjuriesthatcertainpersonalitytraitsmaycause. Onlyone study usedastructured clinicalinterview for thediagnosis ofthepersonality structureanddynamics.28

Theremainingstudiesusedobjectivepsychologicalteststo evaluatepersonality.22---27,29---37_Projective_{psychological}_tests

werenotused.Thisfactmayberelatedtothepracticality ofuseandeaseofapplicationofobjectivetests.However, therearesomelimitationsintheuseofobjectivetestsof personality,inassociationwiththedependenceonhowthe individualreallyperceiveshimself/herself;whetherhe/she isansweringtowhatreally matcheshis/herwayofbeing, orinstead inrelation towhathe/she wouldlike ittobe. Anotherimportantlimitationofthesetestsisthatobjective testscanassessthegeneraltendencyofpatientstorespond totheenvironmentwheretheylive,butcannotdistinguish betweenthestructuralfeaturesandthedynamic character-isticsofpersonality.Carlson40_manifested_his_concern_about

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Itisimportanttomentionthatitisimpossibleto estab-lishaspecificpersonality profileof tinnituspatients;only thepresence ofcertain personalitycharacteristics canbe detectedinthis population;thesefeaturesarealsofound in patients with chronic diseases, suchas chronic pain,41

headache,42,43 _{fibromyalgia,}43 _and _asthma.44 _Some _studies

show that patients withcomplaints of physical symptoms havehigherneuroticismscoresthanhealthyindividuals.45---47

Conclusion

Moststudiesshowasignificantassociationbetween person-alitycharacteristicsandtinnitus.Thesecharacteristicsmay beassociatedwiththeperceptionandannoyanceof tinni-tus,andcontributetothedifficultyofpatients’adaptation tothechronicsymptom.

There is a need for further research using more com-prehensive personality assessment instruments that can contributetoabetterunderstandingofthisphenomenon.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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