Linking Affective and Hearing Sciences—Affective Audiology

Abstract

A growing number of health-related sciences, including audiology, have increasingly recognized the importance of affective phenomena. However, in audiology, affective phenomena are mostly studied as a consequence of hearing status. This review first addresses anatomical and functional bidirectional connections between auditory and affective systems that support a reciprocal affect-hearing relationship. We then postulate, by focusing on four practical examples (hearing public campaigns, hearing intervention uptake, thorough hearing evaluation, and tinnitus), that some important challenges in audiology are likely affect-related and that potential solutions could be developed by inspiration from affective science advances. We continue by introducing useful resources from affective science that could help audiology professionals learn about the wide range of affective constructs and integrate them into hearing research and clinical practice in structured and applicable ways. Six important considerations for good quality affective audiology research are summarized. We conclude that it is worthwhile and feasible to explore the explanatory power of emotions, feelings, motivations, attitudes, moods, and other affective processes in depth when trying to understand and predict how people with hearing difficulties perceive, react, and adapt to their environment.

Introduction

Emotional components have emerged in the audiology literature in recent years, shedding light on how essential affective meanings carried in daily sounds (senders), and how they are perceived (receivers), could impact how we study and practice audiology. Picou et al. (2018) called for research on how patients’ auditory emotional perceptions and experiences are affected by hearing loss. Kraus and White-Schwoch (2017) suggested including factors of emotions and rewards in tinnitus treatment and auditory learning. Both groups highlighted the hearing–emotion connection, suggesting the potential for a subdiscipline of affective audiology. In this review, we discuss the potential value of incorporating affect, and associated methodologies, into audiology from the vantage points of affective and hearing sciences. We provide examples of how this young field could be broadened by incorporating core affective determinants (e.g., emotions, motivations, moods, and attitudes) into audiology research and practice.

Affective Science Pertains to Audiology

Audiology concerns healthy hearing and listening in daily situations that involve auditory communication. Given that affects permeate many aspects of daily life (Zahn-Waxler, 2010), we believe mutual links could exist between the affective and hearing sciences.

Evidence From Neuroscience

Anatomical and functional connections between neural circuits supporting audition and the dominant circuits associated with emotion are well characterized and support this reciprocal link. For instance, the amygdala, a central structure in emotional information processing, is reciprocally connected to the medial geniculate nucleus of the thalamus and the auditory cortex (LeDoux et al., 1984; Viinikainen et al., 2012). This connection allows the transfer of acoustic features of stimuli through forward connections from auditory cortex regions to the amygdala, and the emotional valence of auditory stimuli through backward projections from the amygdala to the auditory cortex (Kumar et al., 2012). The auditory cortex also plays an equivalent and complementary role to the amygdala, decoding complex emotional sounds and sound features that evolve over time (Frühholz et al., 2014). Regardless of whether this enhanced auditory cortex activity (likely, increased auditory sensory processing) is driven by increased emotional decoding in the amygdala (Vuilleumier et al., 2004) or is a complementary emotion processing function different from the affect processing in the amygdala (Pessoa & Adolphs, 2010, 2011), the auditory cortex demonstrates stronger and more robust activity when stimulated by affective sounds than by neutral sounds, similar to the amygdala (Pessoa & Adolphs, 2010).

Animal studies show that lesions in the amygdala interfere with the development of late-conditioned novel tones (Armony et al., 1998) and the response to previously conditioned auditory stimuli (Heldt et al., 2000). These studies suggest that the amygdala influences the long-latency auditory memory network. For example, infusion of sodium salicylate into the lateral amygdala can enhance sound-evoked neural firing activity in the auditory cortex in rats (Chen et al., 2012). Early amygdala damage can alter the ability to process species-specific audio-visual vocalization in rhesus macaques (Payne & Bachevalier, 2019). Human studies have also documented impaired vocal affect perception, especially for fear and anger (Scott et al., 1997), emotion recognition from music (Gosselin et al., 2007), and verbal emotional memory (Buchanan et al., 2001), despite normal hearing in patients with amygdala lesions (Frühholz et al., 2015). These data support the reciprocal impact of the affect processing structures’ function on the auditory function. Details of other bidirectional structural and functional connections between neural circuitry responsible for auditory and emotional information processing can be found in the literature, including networks associated with general affective sound processing (Frühholz et al., 2016), tinnitus (Hu et al., 2021; Kraus & Canlon, 2012), music processing (Peretz & Zatorre, 2005), and auditory hallucination (Marschall et al., 2021; Richards et al., 2021).

In addition to emotions, other aspects of affect (e.g., motivations and moods) are likely to dovetail with audiology. A typical intersection is listening effort, an attentional component of effort closely related to motivation (Sarter et al., 2006) and mood (Erber & Tesser, 1992). Listening effort exertion is presumed to follow a pattern that first increases and then decreases (inverse U-shaped) across easy to challenging listening conditions and low to high motivational arousal based on listening effort models, as people do not need much effort for easy tasks, expend higher effort for moderately difficult tasks and then effectively give up for tasks that are too hard for them (Herrmann & Johnsrude, 2020; Pichora-Fuller et al., 2016). The neural signatures of listening effort have been identified in inverse U-shaped activity as a function of speech degradation in regions such as the left lateral temporal cortex, inferior frontal cortex, premotor cortex (Davis & Johnsrude, 2003; Dimitrijevic et al., 2019; Ryan et al., 2022), and cingulo-opercular network (anterior cingulate and bilateral anterior insulae) (Eckert et al., 2009, 2016; Peelle, 2018). The cingulo-opercular network, in particular, is likely responsible for maintaining tonic alertness to make cognitive faculties available for current processing requirements (Sadaghiani & D'Esposito, 2015) and motivate goal-driven effortful behavior (Holroyd & Yeung, 2012). For example, the anterior cingulate cortex appears to integrate motivational value dimensions (e.g., monetary incentives) and behavior options into a general task value to determine the level of effort needed to sustain optimal performance (e.g., cost-benefit trade-off decision-making) (Apps & Ramnani, 2014; Croxson et al., 2009; Yee et al., 2021). The prefrontal cortex and anterior insulae of the same cingulo-opercular brain valuation system are respond differently to positive and negative information (Harlé et al., 2012; Vinckier et al., 2018). Their activities were reported to regulate individuals’ emphasis on potential rewards/losses, influencing their decision on effort costs (Prévost et al., 2010; Vinckier et al., 2018). With the neural components in and beyond the auditory cortex, the listening effort could thus be considered a combination of the cognitive and affective hearing concepts.

Another typical intersection of affect and audiology is auditory emotion perception. For example, hearing loss is shown to aggravate mood and induce symptoms of depression (for review, see Canbeyli, 2022). This may occur through direct pathways such as reduced perception of spectral, temporal, and amplitude acoustic cues critical for vocal emotion processing (Barrett et al., 2020; Ren et al., 2022; Richter & Chatterjee, 2021). It may also occur through more indirect pathways. For example, reduced peripheral input yields decreased reactivity in brain structures which process emotional information (e.g., amygdala and anterior cingulate cortex), yielding decreased emotion reactivity, hedonic experience and emotion regulation functions (Husain et al., 2014; Rutherford et al., 2017; Wager et al., 2008), which may increase the risk of developing anxiety and depression (Hua et al., 2022; Ma et al., 2022; Tang et al., 2020). Individuals with unipolar depression display activity that is different from never-depressed individuals across a variety of networks subserving cognitive and emotional information processing in response to emotional stimuli (see Jaworska et al., 2015 for a review). Bupropion, an antidepressant, increases reactivity to happy voices in emotion circuits (e.g., superior temporal gyrus, superior and medial frontal gyrus, and insula) compared to the placebo (Hama et al., 2021), despite no change in behavioral performance on vocal emotion judgments. This evidence encourages us to consider the phenomena of compromised affect perception in people with hearing problems within a broader framework. For example, neural-plastic alterations may occur due to long-term hearing deprivation, and manifest as decreased functional connectivity between the amygdala and the auditory cortex, striatum, cingulate gyrus, multimodal processing areas, and frontoparietal control areas (Tang et al., 2020; Xu et al., 2019). Thus, deficits in processing vocal emotions may be partially addressed by techniques that target activity in emotion circuits developed in affective science, in conjunction with current amplification interventions (Cannon & Chatterjee, 2022; Goy et al., 2018; Paquette et al., 2018).

Evidence From Behavior

Audiology researchers are well aware of the increasing empirical evidence that hearing loss and tinnitus are associated with adverse changes in performance and affective variation (e.g., emotions, motivations, and moods), including difficulties in voice (Cannon & Chatterjee, 2019; Laugen et al., 2017; Most & Aviner, 2009; Oron et al., 2020; Picou et al., 2021), musical (Mazaheryazdi et al., 2018), and facial (Saatci et al., 2021) emotion recognition, emotion interpretation of others in certain contexts (Tsou et al., 2021), emotion regulation, and friendship development (Rieffe et al., 2018), forming social connections (Bott & Saunders, 2021; Keesom & Hurley, 2020; Shukla et al., 2020), and difficulty recovering from depression, anxiety, stress, fear, chronic fatigue, and mood changes (Burke & Naylor, 2020; Jayakody et al., 2018; Juul Jensen et al., 2018; Nordvik et al., 2018). Thus, directional paths from hearing impairment to impaired linguistic communication, to low mood have been observed (Brink & Stones, 2007). Hearing impairment is associated with increased psychiatric comorbidity in depression as well as depressive symptomatology (see Canbeyli, 2010 for review). Support for a causal relationship has also been demonstrated, as hearing aids are shown to improve mood (Brewster et al., 2020). Similarly, the effects of auditory stimulation on affective variables can be seen in the lab as auditory stimuli, particularly music, but also including beat patterns and noise stressors, are well-known to affect mood in both humans and animals (see Canbeyli, 2010 for review).

Less attention has been focused on the influence of affect on auditory phenomena. It has been reported that depression, a disorder characterized by profound affective symptomatology, can alter various aspects of auditory processing. For example, depression can impair cortical habituation to vowels and tones (Christ et al., 2008; Michael et al., 2004; Tollkötter et al., 2006) and diminish the auditory looming bias (Riskind et al., 2014). Treating depression treats some aspects of hearing loss, particularly involving perceptual asymmetries (Yovell et al., 1995). Similarly, happiness and sadness reinforce the distracting effect that deviant sounds have on the performance in auditory–visual oddball tasks by prolonging reaction times and reducing accuracy (Pacheco-Unguetti & Parmentier, 2014, 2016). Stress, an integral part of modern life, can influence auditory function in terms of tinnitus, hyperacusis, and noise-induced hearing loss (Horner, 2003; Jafari et al., 2017). Pérez-Valenzuela et al. (2019) suggested that persistent stress could produce auditory sensory deprivation, interfere with the brain–environment connection, and induce hearing impairment likely via the impaired hypothalamic–pituitary–adrenal axis in which unbalanced glucocorticoids and glucocorticoid receptors as a result of stress damage the cochlea's homeostasis and normal sensitivity (Graham & Vetter, 2011; Mazurek et al., 2010, 2012). Faulkner et al. (2021) suggested another plausible pathway via altered sensitivity to noise. The authors reported an association between persistent traumatic stress and the experience of amplified negative reactions to ambient noise, that is, noise sensitivity (Job, 1999), mediated by fear avoidance. According to the authors, stress-related hyperarousal may cause hypervigilance towards noise, yielding avoidance behaviors that provide decreased exposure to noise in the short term, but drive maintenance of noise sensitivity and social withdrawal that could lead to increased attentional load and maladaptation to hearing problem management in the long term. Physical and social acute stresses are also documented to have negative effects on auditory processing through similar pathways (see Jafari et al., 2017 for a review).

Somewhat more evidence is available on the impact of affect on listening efforts. Incentive rewards (Koelewijn et al., 2018, 2021; Zhang et al., 2019), success importance (Richter, 2016), the presence of another individual (Pielage et al., 2021), and stressful instructions (Picou, 2014) were reported to influence listeners’ decisions as to when and to what extent to expend effort to pursue a specific listening goal. Sadness increases auditory distractability (Pacheco-Unguetti & Parmentier, 2014) as well as auditory deviance detection (Pinheiro et al., 2017), likely increasing listening effort.

Current Challenges in Audiology Are Affect-Related

Studying potential connections between affect and audiology, particularly regarding the effects of affect on hearing, could help to address challenges in audiology practice and inspire the development of innovative hearing health interventions and evaluation instruments. For example, affective features of acknowledging hearing impairment (e.g., shame and losing face) are suggested to be hidden influences on whether people will take advantage of services that audiologists provide, and have thus been suggested as targets for audiologists to address (Danermark, 1998).

Hearing Health Campaigns

Due to their invisible nature, hearing problems are largely underrecognized in the hearing care services’ target population. Public education contributes to preliminary self-identification of vulnerability to hearing problems, which is helpful in facilitating prevention and early intervention efforts. Global hearing health campaigns have rapidly grown over the last two decades under the leadership of the World Health Organization World Hearing Day initiative (Chadha & Cieza, 2017, 2018). However, challenges remain in formulating effective motivational message content and devising approaches that translate motivation into action (Sawyer et al., 2019) before the global low hearing intervention rate can be substantially changed (Chien & Lin, 2012; Davis et al., 2016; Ferguson et al., 2017; Hartley et al., 2010; Zhao et al., 2015).

There is a barrier between the known hearing risks/problems, and the unknown health/life concerns and priorities in the target population (Hommes et al., 2018; Tamaskar et al., 2000). Addressing this barrier by matching messages to individuals’ affective states, goals, and attitudes could help increase persuasive power (Teeny et al., 2021), and may help to formulate concerns that are different from what hearing professionals assume the target population would need and care about, as has been reported for depression (Siegle et al., 2019).

Attention in hearing health campaigns (domestic and global) is almost exclusively paid to non-affective recipient characteristics (e.g., sex, age, and clinical hearing conditions) according to the annual reports of registered worldwide campaign activities on the World Hearing Day official website (https://worldhearingday.org). As an example of the potential impact of this approach, cultural differences have been observed to affect approaching and avoiding orientation (Hamamura et al., 2009; Zhang et al., 2021) such that affective goals (e.g., “feeling good”) are prioritized in American and European cultures, but explicitly avoided in Chinese individuals. And yet, hearing campaigns in China have been consistent with the American/European model of recommending hearing intervention to improve positive affect (e.g., “feel better” and “happy living”) (Liang & Liu, 2021). An affective audiology perspective would suggest, instead, the potential utility of targeting affectively prioritized features in Chinese culture, for example, being stronger support for one's family. Cultural differences have also been observed in other facets that could affect hearing campaign messaging such as creativity (Lubart, 2010), the need for cognition (Zhang et al., 2021), hedonic-utilitarian values (Ozen & Kodaz, 2012), self-construal and affective valence (Kafetsios et al., 2018), and attitude function (Choi et al., 2020). Using more affective language with hedonic-oriented recipients (Rocklage & Fazio, 2020) or cognitive language with cognition-oriented recipients (Haddock & Maio, 2019) may thus be useful. Nevertheless, affective science also suggests the utility of minimizing negative interpretations by recipients, including boredom (Clark et al., 2008), perception of attempts at manipulation (Briñol et al., 2017), or unfair or stereotypic judgments about groups (Derricks & Earl, 2019).

Other dimensions in effective persuasive communication are explicitly related to affect. The sources of the message (e.g., experts, government authorities, or representatives from specific groups) impact the level of trust, confidence, and comfort in the target recipients (Kruglanski et al., 2005). The setting/context in which messages are delivered can use affective associations to promote persuasion and action-taking (Breves & Heber, 2020; Hasford et al., 2015). It may thus be beneficial to explore the persuasion-related and affective psychology literature to strengthen hearing health public campaigns.

Intervention Uptake

Low hearing intervention uptake has been an ongoing challenge (Davis & Smith, 2013; Orji et al., 2020). It mainly manifests as not using hearing aids/cochlear implants/assistive listening devices when one should or not engaging in auditory rehabilitation programs when one could benefit from them (Simpson et al., 2019). We summarized a consolidated list of the investigated nonaudiological factors influencing hearing aid uptake and use based on the extensive reviews by Knudsen et al. (2010) (included 39 studies between 1980 and 2009), Jenstad and Moon (2011) (included 14 studies between 1990 and 2010), Meyer and Hickson (2012) (included 22 studies between 1990 and 2010), McCormack and Fortnum (2013) (included 10 articles between 2000 and 2012), and Knoetze et al. (2023) (included 42 studies between 2011 and 2022). These review articles were selected to cover a fairly long time window of the literature without gaps (from 1980 to 2022) and a wide age range (from 18 to 95 years old). Non-audiological factors outlined in the review articles were merged into a complementary list of barriers and facilitators to hearing help-seeking and hearing aid uptake (see Table 1). Among the 127 articles included in the above reviews, there were 43 duplicate articles, which were removed from the article count in Table 1.

Table 1.

Nonaudiological Factors Influencing Hearing Aid (HA) Uptake and Use With Number of Supporting Studies (in Parenthesis).

Factor	HA uptake	HA use
Age	± (26)
Education	± (12)
Sex	± (22)
Socioeconomic status	+ (12)
General health	– (6)
Locus of internal control	+ (2)
Ego strength	+ (1)
Cognitive anxiety	+ (2)
Distress	± (2)
Depression	± (1)
Technology commitment	+ (2)
Stigma	– (5)
Concern regarding the cost	– (2)
Language level used by audiologists	– (1)
Denial	– (1)
Readiness for change	+ (4)
Autonomous motivation	+ (2)
Self-acceptance	– (1)
Self-efficacy	± (2)
Maladaptive behaviors	– (1)
Subjective norm	+ (2)
Subjective norm * Trust	+ (1)
Attitudes toward behavior and control	+ (2)
Attitude toward own hearing loss	+ (4)	+ (3)
Attitude toward hearing aids	+ (3)	+ (4)
Self-reported hearing difficulties	+ (9)	+ (3)
Counselling		+ (2)
Dexterity (impression about the audiologist)		+ (2)
Lifetime experience with hearing aids		+ (2)
Hysteria		+ (1)
Expectations		+ (1)
Number of major life events		+ (1)
Adaptation period		– (1)
Depression/obsession		– (1)
Socioeconomic status: income level		– (1)
Activity of daily living		– (1)
Medication		– (1)

Note: “+” indicates a positive association between the factor and the outcome, “–” indicates a negative association, and “±” indicates a controversial association including no association.

Aside from demographic factors, most non-audiological factors appeared to be affective and related to stigma (of hearing loss as well as hearing aid use) and identity/attitudinal beliefs (Barker et al., 2017; Meyer et al., 2014). As a study by Ruusuvuori et al. (2021) and from the self-reports of participants with hearing loss/hearing aids during narrative interviews (Scharp & Barker, 2021; Wallhagen, 2010), little progress has been observed over the past decade on changing stigma at the societal, interpersonal, or individual levels, despite efforts such as moving hearing aids culturally from being medical devices to fashion accessories like glasses, which have more complex stigma profiles (Harris et al., 1982) and for which inclusion of modern aesthetics have been demonstrated to decrease stigma (Dos Santos et al., 2022). Thus, learning from research on affective features such as stigma from social psychology and affective science may help audiology researchers and clinicians to increase hearing aid use and develop more acceptable interventions.

For example, most reported stigmas in audiology regard self-judgment and perceptions of judgment by others, including attitudes about the nature of the person (e.g., being whole vs. not whole, able vs. disabled, smart vs. cognitively impaired), ageism (e.g., being an “old fogey”), and vanity (e.g., being unattractive) (Preminger & Laplante-Lévesque, 2014; Wallhagen, 2010). Bos et al. (2013), in agreement with Goffman (2009), theorized that public stigma is at the root of other stigma manifestations (i.e., self-stigma, stigma by association, and structural stigma). Given the evidence that self-perception changes may arise from hearing loss/hearing aid use (Barker et al., 2017; Hogan et al., 2009), we speculate that for hearing loss and/or hearing aid use, self-stigma may also feed into public stigma, particularly if hearing impairments engender confusion and frustration in communication. If that were the case, focusing on stigma reduction at the individual level might be important in addition to the public level. Specific approaches to stigma reduction, which might apply to audiology, appear effective, including introducing a new “label” as in weight-related problems (DePierre et al., 2013), using competence messages as in individuals with mental illness based on expectation states and affect control theories (Kroska & Harkness, 2021), and embracing a continuum (psychopathology and normality are separate points on a fluid continuum) rather than categorical (psychopathology and normality occupy distinct social categories separated by a rigid boundary) belief towards mental health conditions (Thibodeau, 2020).

The neuroscience of stigma is also increasingly well understood, involving the ventral anterior cingulate cortex (associated with emotional self-regulation, affective information processing, and social feedback), medial prefrontal cortex, amygdala, insula, and right orbital gyrus (associated with social knowledge) (Krendl et al., 2008; Moor et al., 2012; Quadflieg et al., 2009; Wraga et al., 2007). This work suggests the potential for novel interventions for stigma belief formation and maintenance rooted in neuroscience.

Motivation may help to initiate the self-stigma reduction process. The health belief model of D’Haese et al. (2018) emphasizes the utility of motivation in facilitating change in health behaviors and perceptions. Thus, reminding individuals with hearing impairment who are not sufficiently motivated to accept that their hearing problems present an opportunity to unlock self-improvement (e.g., being stronger, more open-minded, understanding, or patient) might help move them toward the hearing status they need and want.

Full Picture of an Impaired Auditory System

The affective states/moods of the respondents are rarely evaluated at the time of testing in most hearing assessments. Given the bidirectional relationships between hearing and affect which we have described, assessing the affective state throughout a quantitative and qualitative hearing assessment might give a fuller picture of the dynamic functional range (e.g., possible potential) of an impaired auditory system.

Small effects across a variety of studies suggest that affective features have some, if limited impact on auditory perception at the basic pure tone level. For instance, positive and negative word primes facilitate high- and low-pitch tone perception, respectively, although the tones alone are not judged to have an affective valence (Weger et al., 2007). Similarly, angry voice prompts modulate auditory spatial attention and facilitate neutral pure tone detection (Ceravolo et al., 2016). Arousal affects the threshold at which masked stimuli can be perceived (Bolders et al., 2017). People high in arousal give higher magnitude estimates to the loudness of a 1,000-Hz 80-dB SPL tone than those low in arousal under stress (Dess & Edelheit, 1998). Hand-holding, which decreases reactivity in brain areas that are reactive to threats (Coan et al., 2006), decreases reactivity to startling sounds (Kerr et al., 2018). In auditory brainstem responses to speech, subcortical neural activity increased as early as 20 ms after stimulus onset for negative compared with neutral speech (Wang et al., 2009). Auditory P300 amplitudes and area-under-the-curve are larger when a sad mood is induced (Yamamoto et al., 2000). Mood-congruent brain potentials are observed for auditory stimuli (e.g., larger N400 event-related potentials for negative stimuli in negative moods) (Egidi & Nusbaum, 2012). Although many of the abovementioned effects are fairly small, they suggest the potential for affective information to affect some patients seen in daily audiology practice. As these effects may be larger for some patients than others, evaluating variation in hearing ability under different affective conditions at the individual patient level may provide useful hints for fine-tuning hearing aids in different listening programs, or may help to guide clinicians’ psychosocial advice to clients.

Affective states also impact high-level attention, memory, reasoning, and responding cognitive processes (Mitchell & Phillips, 2007) which interact with hearing. For example, music-induced positive mood is associated with increases in the event-related brain potential response to distractor sounds (e.g., N1/MMN) (Putkinen et al., 2017). Spies et al. (1996) tested participants on a simple word span task (short-term verbal memory) and a more complex reading span task (working memory) following mood induction. They found that while negative mood did not decrease the executive capacity, positive mood resulted in greater deficits in the complex span task than in the simple word span task. Cognitive reasoning and response processes related to hearing can be impacted by affective factors with many other similar examples (Schwarz & Clore, 1983; Tiedens & Linton, 2001).

Affective variables also appear to affect how people understand and relate to their hearing problems. For example, people with lower moods rate themselves as having hearing-loss-related quality of life issues (Preminger & Meeks, 2010). Negative affective states induced by the COVID-19 pandemic have been observed to worsen self-perceived tinnitus loudness, increase annoyance, and decrease quality of life (Aydoğan et al., 2022).

There are many theories of how affective states could affect sensory and cognitive processing that may underlie the above-mentioned phenomena. For example, Schwarz (1990, 2011) suggests that negative affective states inform us that our current situation is problematic and an action might be needed to change it; therefore, effortful, detail-oriented, analytical processing and risk-avoiding strategies are fostered to maximize positive outcomes. By contrast, positive affective states inform us that the current situation is safe and satisfactory. They may not signal that a particular action or cognitive effort is required other than by following the currently active goals, resulting in a global top-down processing style and medium-risk approaches (Bless et al., 1996). Hence, affective states might elicit different motivations and effort exertions. Bower (1981) proposes that cognitive and sensory processing will often be mood-congruent due to spreading activation from representations of recalled mood-congruent memories. Gendolla (2000) proposes that cognitive processes and hedonic motivation act as mediators of mood–behavior linkage. Thus, audiologists working to understand affective influences on hearing have a wealth of theory, as well as empirical data to appeal to.

That said, affective influences on other sensory domains may be better explored than hearing, and factors such as processing motivation and capacity (Fiske & Neuberg, 1990) could vary differentially across modalities. Thus, more data on affect/sensory-processing in the auditory domain may be useful to acquire, particularly as is relevant to audiology examinations. For example, whether there are ranges for routine audiological examinations that affect changes in performance, or whether amplification prescriptions for hearing loss and sound treatment for tinnitus account for the potential affect-dependent boosting or hindering of the hearing perception abilities. Potentially accounting for affective style could help to promote individualized treatment, increasing user satisfaction and compliance. It may also be useful to examine whether self-affect-regulation strategies compensate for the cognitive decline associated with hearing problems, including lack of motivation to listen, misinterpretation of emotional vocal sounds in social environments, and negative judgment bias on quality of life and well-being caused by hearing problems.

Tinnitus

Personalizing treatment for tinnitus has been a challenge in research or clinical practice (Mazurek, 2018; Simoes et al., 2021) as the experience of tinnitus is very individual (Hall et al., 2016). Attending to affective features may help in this endeavor. Largely nonaffective characteristics are often considered in tinnitus such as severity, duration, and presence of comorbidities; affective features are relegated to consideration of clinically relevant individual characteristics such as anxiety (Kumbul et al., 2022) and depression (Baguley et al., 2013; Van der Wal et al., 2020). However, it remains unclear why some people are distressed by tinnitus while others are not. Similarly, the wide spectrum of therapeutic strategies for tinnitus treatment could indirectly address affective features, but these are not centralized, for example, in interventions ranging from transcranial magnetic and vagus nerve stimulation, cochlear implant electrical stimulation, cognitive behavioral therapy or sound therapy (Lopez-Escamez & Perez-Carpena, 2022) to antidepressants (Baldo et al., 2012); their outcomes vary and the positive effects on tinnitus perception modification are often short-lasting (Czornik et al., 2022; Katiri et al., 2021).

Affect-directed approaches might be helpful to move closer to precision tinnitus treatment. For example, in light of the evidence that tinnitus and emotion both depend on time-of-day (Heller et al., 2021; Probst et al., 2017; Wright & Woods, 2020), Simoes et al. (2022) adopted ecological momentary assessment (EMA) by using a tinnitus mobile app to track daily tinnitus symptoms and psychological variables in 278 app users between 2014 and 2020. They found that emotional arousal, overall stress, mood, and concentration influenced tinnitus loudness and distress on the day and the subsequent days at the individual level.

More generally, accounting for the affect could improve tinnitus treatments. In a randomized controlled trial, Westin et al. (2011) compared the effects of Acceptance and Commitment Therapy (ACT) with Tinnitus Retraining Therapy (TRT) on tinnitus impact, and showed that ACT, which consists of mindfulness and acceptance training, significantly outperformed TRT on tinnitus impact, evaluated by the Tinnitus Handicap Inventory (Newman et al., 1996). Similarly, a small sample randomized controlled trial demonstrated that a mindfulness meditation/cognitive behavioral therapy (CBT) approach of four sessions led to a significant reduction in tinnitus-related distress (Sadlier et al., 2008). These findings suggest that adopting methods from affective science could impact tinnitus recovery.

Such affect-directed approaches may enhance available tinnitus treatments by taking into account the fluctuation of emotions and tinnitus over time so as to provide an integrated and adaptive protocol for each individual tinnitus sufferer. For example, when a treatment is prescribed for a tinnitus patient based on a cross-sectional evaluation of tinnitus loudness and distress, there will be times when the mood fluctuation changes the tinnitus loudness and distress so much so that the outcomes are drifted away from the prescribed goal. Antidepressants and CBT, in particular, are well known to have effects on emotion. More specific affective modifications such as incorporating emotion regulation strategies could explicitly address emotional features (Picó-Pérez et al., 2017).

Data-driven tinnitus intervention recommender systems, such as the tinnitus research initiative (TRI) database (Landgrebe et al., 2010) and the Tinnitus-Assessments, Causes and Treatments (TIN-ACT) database (TIN-ACT, 2017), may thus benefit from including affective features to improve their performance.

Incorporating Affect Into Audiology

The previous section showcased examples of how research in affect-related disciplines could expand our thinking about specific challenges in audiology. There may be more connections between affect and hearing to explore once audiology scientists become better-versed in affective constructs and assessment methodologies.

Access to Affective Constructs

Affect is a general concept that refers to consciously accessible feelings. These are associated with emotions, physical sensations, motivations, attitudes, moods, and affective traits (Fredrickson, 2001), constructs that both intersect and differ. Comprehensive definitions of core affective determinants can be found in the affective science literature, for example, “emotion” as concerning momentary affective states on the order of seconds to minutes (Barrett et al., 2016; Cabanac, 2002; Reeve, 2018), “motivation” as concerning action tendencies largely governed by reward and punishment (Buck, 1988; Peters, 2015; Reeve, 2018), “mood” as concerning sustained emotion states on the order of hours to days (Barrett et al., 2016; Batson et al., 1992; Ekkekakis, 2012; Portner, 2018), and “attitude” as concerning beliefs and their application to emotional appraisals (Eagly & Chaiken, 1998; Greenwald, 1968; Schwarz, 2007). In relation to hearing/listening, we suggest applying the following distinctions when searching for relevant literature. The “emotion” literature can inform how affective intensity and hedonic content (pleasure/displeasure) interact with how one hears and listens in the moment. Literature on “motivation” can help to suggest why one prefers to listen under certain conditions over others. Literature on “mood” can inform how sustained affective states affect hearing performance. Literature on “attitude” can inform about how one's beliefs shape the perceived acoustic information.

Advances in affective science have produced some useful resources enabling people from other disciplines quickly locate affective constructs of interest in structured ways. One such resource is the Research Domain Criteria matrix launched by the National Institute of Mental Health (Insel et al., 2010), in which the matrix rows represent various constructs grouped hierarchically into broad function domains (i.e., negative valence systems, positive valence, cognitive systems, social processes, arousal and regulatory systems, and sensorimotor systems), and the columns denote levels of analysis (i.e., genetic, molecular, cellular, circuit, individual, family environment, and social context). This corpus of constructs could help to explore possible affect pathways associated with hearing/listening and provide information about the frequently used paradigms in studying those constructs. For example, audiology researchers may find studying the connection between strategic listening effort allocation and two distinct action tendencies, approach, and avoidance (grouped in the negative valence systems), worthwhile. This could be done via the fear and reward neural circuits using behavioral approach paradigms. Audiology researchers may also be interested in studying emotion-regulation strategies (e.g., mindfulness meditation, cognitive reappraisal, and acceptance) for tinnitus treatment based on the salience and executive network circuits activated during rumination-induction paradigms (e.g., Brandeis et al., in press).

Appealing to other affect science literature may help audiologists to disambiguate emotional constructs. For example, Ekman (1992) posits a discrete and limited set of basic emotions (e.g., fear, happiness, sadness, calmness, sorrow, and shame), each with unique neural, behavioral, psychological, and physiological manifestations. Standardized emotion-evoking stimuli using this framework are available, for example, Cowen et al. (2021). Alternately, a common dimensional framework, for example, Russell (1980), holds that emotions can be placed on a circumplex defined by valence (pleasure–displeasure continuum) and arousal/alertness (activation–deactivation continuum) axes (Barrett, 2006; Larsen & Diener, 1992). Discrete emotions can thus be understood as reflecting linear combinations of valence and arousal (Posner et al., 2005). Typical emotion-inducing stimuli, validated in line with this theory, include the International Affective Picture System (Lang, 2005), International Affective Digital Sounds (Bradley & Lang, 2007), and Affective Norms for English Words (Bradley & Lang, 1999). Both of these frameworks, as well as many others, have been extensively used in the affective science literature, as shown in Table 2, and each has advantages that the audiology researchers can build on. Thus, there are no lack of potentially well-fitting theoretical frameworks for the aspiring affective audiologist to appeal to.

Table 2.

Representative Audiology and Affective Constructs Measured by Various Qualifying Method Categories. The Same Table, With Relevant References for Each Construct, is Included as a Supplement.

Category	Audiology constructs	Affective constructs
Autonomic nervous system physiological measures (e.g., electrodermal response, heart rate, heart rate variability, blood pressure, pupil dilation, sweating, and skin temperature)	Sound detection; Speech perception; Ambiguous speech comprehension; Auditory processing speed; Exerted listening effort.	Arousal; Valence; Vigilance; Emotional salience; Habituation; Rumination Motivation; Fatigue; Engagement; Alertness; Stress.
Central nervous system physiological measures (e.g., functional magnetic resonance imaging, electroencephalography, functional near-infrared spectroscopy, positron emission tomography)	Tinnitus perception; Hyperacusis; Linguistic processing of speech; Affective speech processing; Sound localization; Auditory attention; Auditory memory; Auditory discrimination; Auditory plasticity; Hearing-related emotional impairment.	Affect discrimination; Affective personality; Emotional self-monitoring/regulation; Affective decision-making; Interoceptive self-monitoring; Affective disturbances; Affective response; Emotional contagion; umination.
Behavioral measures (i.e., response time and performance accuracy)	Hearing sensitivity; Auditory discrimination; Speech perception; Speech recognition; Speech comprehension; Auditory attention; Auditory adaptation/acclimatization; Auditory emotion recognition; Exerted listening effort.	Emotion perception and recognition (e.g., excitement, elation, joy, surprise, calmness, sadness, anger, gratitude, disgust, fear, attractiveness, and shame); Emotion expression; Approach–avoidance.
Self-reported measures (e.g., survey, visual analog rating)	Perceived disability; Assessed listening effort; Experienced listening effort; Hearing-related emotion experience (e.g., loneliness, social isolation, depression, stress, distress, anxiety, hearing acceptance, and satisfaction with amplification).	Emotion experience (e.g., appreciation, happiness, relaxation, calmness, excitement, sadness, anger, fear, stress, disgust, envy, shame, guilt, pride, satisfaction, awe, craving, loneliness, empathy, frustration, mental pain, contempt, anxiety, depression); Emotion regulation; Need for affect; Affective attitude.

Measurement of Affective Constructs

Audiology and affective science frequently make use of similar assessment technologies as shown in Table 2 (see Supplemental Material document with reference for Table 2). Thus, assessment of affective components can be readily integrated into hearing research and clinical practice where adequate technologies are available, potentially leading to new treatment and personalization targets. Cognizance of affective moderation of hearing assessment measures may also illustrate alternate interpretations for data which is routinely acquired in audiology. For example, the cingulo-opercular neural network activity captured by functional brain imaging measurements can simultaneously reflect listening effort in difficult speech perception tasks (Eckert et al., 2016) and affective-related functions such as alertness maintenance (Coste & Kleinschmidt, 2016; Sadaghiani & D'Esposito, 2015) and self-awareness of difficulty in action selection (Desender et al., 2021). This overlap raised the question of what is being measured in terms of listening effort (Francis & Love, 2019): is it cognition, affects, or both? Is it possible to investigate the demanded (associated with task properties), exerted (actual effort expenditure), and self-assessed (feelings about effort) efforts separately? Acknowledging these relationships thus situations audiology constructs in a wider range of perspectives, so that explanations of hearing/listening behaviors are not limited to the sensory and cognitive domains. As in hearing literature (Başar-Eroglu et al., 1992), nuances such as the time windows over which reactivity are assessed are equally important to attend to in the emotion domain (Papousek et al., 2011; Siegle et al., 2008, 2015).

Other psychophysiological measurements, long used in cognitive and affective sciences but rarely in audiology, are rapidly becoming popular as objective approaches to evaluate auditory information processing and the related conscious control in hearing research. Thus, the cognitive and affective science literature may have guidelines to appeal to for accurate recording, preprocessing, analysis, reporting, and interpretation involving a wide variety of cognitive and affective influences on the employed measures, for example, pupillary reactivity (Steinhauer et al., 2022), heart rate and heart rate variability (Berntson et al., 1997; Jennings et al., 1981), electrodermal activity (Boucsein et al., 2012), electroencephalogram (Keil et al., 2014; Pivik et al., 1993), event-related potentials (Picton et al., 2000), respiration (Ritz et al., 2002), electromyography (Fridlund & Cacioppo, 1986), startle eye-blink electromyography (Blumenthal et al., 2005), magnetoencephalography (Keil et al., 2014), impedance cardiography (Sherwood et al., 1990), functional near-infrared spectroscopy (Yücel et al., 2021), and functional magnetic resonance imaging (Poldrack et al., 2008).

Methodological Considerations

There are unique considerations that introduce complexity into the use and measurement of affective features, some of which may interact with how they are applied in the context of audiology. We list a number of these considerations in this section.

Affective reactivity may be moderated by beliefs. For example, anger is often assumed to promote aggression (Anderson & Bushman, 2002), and excitement to promote creativity (Baas et al., 2008). These effects depend on participants’ expectations/beliefs in these effects (Tamir & Bigman, 2018). Similarly, attitudinal belief in success likelihood promotes actual success in emotion regulation tests (Bigman et al., 2016).

Affective factors may modulate the success of hearing interventions. If people with biological hearing problems have mentally adapted to them using efficient coping strategies and/or highly supportive families and communities, aggressive interventions in such scenarios might introduce stigma yielding negative affect, which could compromise the effectiveness of the interventions.

Coherence across the experiential, behavioral, and physiological responses to emotions is of only moderate magnitude (Mauss et al., 2005), just as various listening effort measurements lack correlation (Alhanbali et al., 2019; Lau et al., 2019). Coherence varies depending on the test conditions; therefore, multiple measures of affective variables may be desirable for complementary interpretations of experimental results.

Although only correct trials are generally analyzed in audiology studies, physiological reactivity to incorrect trials carries important affective information (e.g., stress, boredom, or fatigue) (Amodio et al., 2008; Salomone et al., 2021; Yakobi et al., 2021). Performance is often operationalized in terms of error rate (lapses in attention) and reaction times (processing time), both of which are sensitive to internal (e.g., specific combinations of task parameters used) and external (e.g., time of day, personality, sex, environment, motivation, anticipation, and mood) factors which can interact with affect. Including the incorrect/error trials in the psychophysiological analysis could help investigate the origins of the listeners’ capabilities in error detection and remedial actions such as error inhibition, immediate error correction, and error compensation.

Unlike the fairly stable development of hearing loss with age, affective features change with development and are subject to many moderators. For instance, emotion understanding develops throughout childhood, adolescence, and sometimes into adulthood (Kramer & Lagattuta, 2022). Emotion regulation is expected to mature through adolescence as prefrontal brain regions mature, though this trajectory may vary depending on socioeconomic status and its impact on the family's emotional context (Herd et al. (2020)). Similarly, the well-documented increased preference for attending to and remembering positive information over negative information with age might depend on cognitive load and/or perceived time horizon at evaluation (Carstensen & DeLiema, 2018). The complexity of developmental variations in affect with age implies that age and associated moderation effects may be useful to account for when assessing interactions between hearing problems and affective states.

While most auditory research is based on the investigation of fine-grained differences in auditory perception requiring high-level acoustic standardization and calibration across systems and settings, the study of affective speech perception may benefit from data collection under less precisely controlled environmental conditions (e.g., the Internet) to reveal more ecologically valid estimates of affect-related hearing (Honing & Ladinig, 2008). Knoll et al. (2011) provided compelling support for the validity of conducting emotional speech perception experiments via the Internet, specifically when giving participants the freedom to choose the volume level, environmental set-up, and stimuli reproduction system. They were able to replicate the laboratory-controlled affective speech ratings in this, less controlled, Internet environment.

Summary and Conclusions

We have suggested that affect has strong influences on how we perceive and behave in the world. Our goal in the present selective review was to demonstrate that affective factors could impact hearing/listening functions (sensitivity and cognition) and experiences. We have thus suggested augmenting the current literature on affective phenomena as health outcomes of hearing problems in audiology science to account for potential moderating roles of affect on hearing assessments, and more broadly, to highlight a wide variety of potential links between affective science and audiology. Our hope is that exploiting these links will help overcome ongoing challenges in hearing health service research.

We have further suggested that future clinical practice and research aimed at identifying the contribution of affective factors to hearing/listening phenomena can build on general theories in affective science and the methods developed to investigate them. For example, if clinicians are already informally checking clients’ feelings during the appointment, endorsing items from formal lists of emotional descriptors (e.g., Watson et al., 1988) could help to standardize these assessments. Asking clients about relationships between their emotional states and their hearing could also be useful. If clients report affect-mediated hearing problems, then clinicians may want to consider administering a mood-induction prior to standardized hearing assessment, potentially by using the types of standardized emotion-evoking stimuli mentioned earlier. If reported hearing problems involve emotion recognition, it may be useful to check hearing in response to calibrated emotional stimuli designed for emotion recognition evaluation, such as the Ryerson Audio-Visual Database of Emotional Speech and Song (RAVDESS) (Livingstone & Russo, 2018), expanded International Affective Digital Sounds database (Yang et al., 2018), diagnostic analysis of nonverbal accuracy (DANVA) (Nowicki & Duke, 2001), or the Hoosier Vocal Emotions Corpus (Darcy & Fontaine, 2020). A test result consistent with the client's report (e.g., hearing is worse in terms of elevated pure tone thresholds or decreased speech intelligibility/vocal emotion perception when in an upset or anxious mood) might suggest a need to modify the current intervention to foster personalized optimal hearing device use, such as activating a new listening program in the hearing aids with amplifications specific for listening during highly anxious periods, and/or creating an individualized daily hearing aid wearing schedule based on the client's mood changes. If hearing-related distress exists, psychological therapies such as acceptance and commitment therapy, investigated by Molander et al. (2018) can be considered. Consideration of affective, as well as hearing outcome measures may also be warranted. We are optimistic that as audiology and affective science become ever more integrated, more practical uses of each discipline in the other's practices may emerge.