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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Health Psychol. 2022 Mar;41(3):178–183. doi: 10.1037/hea0001113

PTSD Symptoms and Tinnitus Severity: An Analysis of Veterans With Posttraumatic Headaches

John C Moring 1, Casey L Straud 1,2,3, Donald B Penzien 4, Patricia A Resick 5, Alan L Peterson 1,2,3, Carlos A Jaramillo 2,6, Blessen C Eapen 7,8, Cindy A McGeary 1,2, Jim Mintz 1,2, Brett Litz 9,10,11, Stacey Young-McCaughan 1,2, Terence M Keane 10,12, Donald D McGeary 1,2,6; Consortium to Alleviate PTSD
PMCID: PMC9809199  NIHMSID: NIHMS1854931  PMID: 35298210

Abstract

Objective:

Tinnitus and posttraumatic stress disorder (PTSD) are among the top service-connected disabilities within the Veterans Health Administration. Extant research shows that there is considerable overlap between tinnitus-related distress and PTSD, including sleep difficulty, irritability, hyperarousal, and concentration problems. However, no studies have prospectively examined the relationship between the two disorders. The purpose of this study was to examine that relationship.

Methods:

Participants (N = 112) with posttraumatic headache completed measures of tinnitus and PTSD. Correlational analyses and analyses of variance were conducted to examine the associations with PTSD symptom clusters and factors of tinnitus-related distress.

Results:

Approximately, half of participants with tinnitus demonstrated severe impairment. Correlational analyses indicated that reexperiencing, avoidance, negative emotions and cognitions, and hyperarousal PTSD symptoms were significantly related to many factors of tinnitus-related distress, including intrusiveness of tinnitus, perceived loudness, awareness, and annoyance. Participants with severe tinnitus demonstrated significantly greater reexperiencing, negative mood/cognitions, hyperarousal, and PTSD total severity compared to those with mild or moderate tinnitus.

Conclusions:

Trauma therapists should assess for the presence of tinnitus in order to more fully conceptualize key health problems of help-seeking patients. Heightened psychological symptoms seemingly related to PTSD may be a function of tinnitus-related distress.

Keywords: tinnitus, stress disorders, veterans, brain injuries

Over 2 million U.S. military veterans have a diagnosis of tinnitus, making the auditory disorder the most common service-connected disability (Department of Veterans Affairs [VA], 2019). The deleterious effects of tinnitus include emotional, cognitive, and behavioral symptoms (Hesser & Andersson, 2009; Kaldo et al., 2008; Moring et al., 2015, 2016), and approximately 10% of individuals with tinnitus reporting a significant decrease in quality of life as a result (Davis & El Refaie, 2000). Development of tinnitus among veterans is associated with increased exposure to acoustically traumatic events, including gunfire, improvised explosive devices (IEDs), mortar attacks, and rocket propelled grenades (RPGs; Moring et al., 2018). Given that over 2 million active duty service members were deployed since September, 11, 2001 (Denning et al., 2014), there is increased concern about the growing prevalence of tinnitus among active duty service members (Moore et al., 2019).

Commonly comorbid with tinnitus is posttraumatic stress disorder (PTSD). A chart review found that 34% of patients enrolled in a tinnitus clinic also had a diagnosis of PTSD (Fagelson, 2007). PTSD is a psychiatric condition characterized by anxiety and change in mood as a reaction to a traumatic event, and it includes symptoms of reexperiencing, avoidance, negative alterations in cognition and mood, and hypervigilance, all of which must persist longer than 1 month to meet established diagnostic criteria (American Psychiatric Association, 2013). According to the VA (2017), PTSD is the third most common service-connected disability, behind hearing loss and tinnitus. Symptoms of PTSD appear to overlap with tinnitus-related distress, including concentration problems, sleep difficulties, irritability, hypervigilance, and changes in mood and cognition (Fagelson, 2007; Fagelson & Smith, 2016; Hinton et al., 2006). Veterans with both PTSD and tinnitus self-report significantly less tinnitus self-efficacy and significantly more tinnitus handicap compared to individuals with tinnitus and any other psychiatric condition or to individuals with tinnitus alone (Fagelson & Smith, 2016).

Onset of tinnitus may also occur after sustaining a traumatic brain injury (TBI; McCrory et al., 2013). Other symptoms after TBI can include depression and anxiety, as well as dizziness, balance problems, fatigue, and posttraumatic headache (PTH; McAllister & Arciniegas, 2002). PTH is defined by the International Classification of Headache Disorders [ICHD-3, (IHS, 2013)] as the development or worsening of headache within 7 days of head injury or recovery from loss of consciousness. However, McGeary et al. (2020) established that PTH onset of 7 days after head injury is not significantly different than onset of PTH of up to 3 months in terms of headache severity and comorbidity. Additionally, onset latency did not differ between the two groups based on sex, headache phenotype, and mechanism of head injury. Tinnitus and hyperacusis have been shown to contribute to PTH (Jaramillo et al., 2016), and emotional distress stemming from symptoms of PTSD have been associated with disability related to headache (Rosenthal et al., 2013). We are aware that tinnitus and comorbid PTSD and PTH present as a significantly greater clinical concern compared to any of those disorders alone. Given the high rates of comorbidity among tinnitus, PTSD and PTH, results from the current study can be generalized to military service members and veterans.

The primary aim of the study was to evaluate the relationship between tinnitus-related distress on the Tinnitus Functional Index (TFI) and PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) at baseline assessment among post-9/11 military veterans seeking treatment for PTH symptoms. It was hypothesized that dimensions of tinnitus-related distress, including intrusiveness, lack of sense of control, cognitive interference, sleep disturbance, auditory issues, relaxation issues, reduced quality of life, and emotional distress would all be significantly associated with PTSD symptom clusters of negative alterations in cognition and mood and hyperarousal. It was also predicted that PTSD symptom scores would significantly differ based on whether participants were classified as having mild, moderate, or severe tinnitus.

Methods

Participants

Participants (N = 112) were a subsample of veterans with reported tinnitus enrolled in a larger randomized controlled trial (McGeary et al., 2021) comparing cognitive-behavioral therapy (CBT) for headache, individual Cognitive Processing Therapy (Resick, Monson & Chard, 2017) for PTSD, and treatment as usual (TAU). As seen in Table 1, participants were predominantly White (64.5%) males (87.3%) who served in the U.S. Army (78.4%) in support of Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), or New Dawn (OND) and were confirmed to have a diagnosis of PTH through a consensus process (McGeary et al., 2020). PTH is defined as chronic headaches for more than 3 months for individuals who sustained a TBI and reported (1) onset of headaches post-traumatic brain injury (TBI) or (2) exacerbation of intensity, frequency, or duration of headaches, within 3 months post-TBI (Headache Classification Committee of the International Headache Society, 2018). Participants must have been medication stable for 6 weeks prior to their inclusion in the study and have had symptoms of PTSD. PTSD was defined as having experienced a Criterion A event according to the Diagnostic and Statistical Manual of Mental Disorders, (5th ed.; DSM-5; American Psychiatric Association, 2013), at least one intrusion symptom, at least one avoidance symptom, and a PCL-5 score of 25 or greater.

Table 1.

Sample Demographics

n %
Gender
 Males 96 87.3
Race
 White 56 51.4
 Black 22 20.2
 Other 31 28.4
Ethnicity
 Hispanic 60 55.0
Relationship status
 Married 71 64.5
 Never married 23 20.9
 Separated/divorced 16 14.5
Education
 High school diploma/GED 13 11.8
 Some college/associate degree 61 55.5
 Four-year/graduate degree 35 31.8
Service branch
 Army 87 78.4
Pay grade
 Enlisted 103 92.0
Duty type
 Combat 62 56.9
 Combat Support 19 17.4
 Combat Service Support 28 25.7
Post-9/11 deployments
 1 51 45.9
 2 29 26.1
 3+ 31 27.9
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Note. GED =Graduate Equivalent Diploma. Tinnitus Functional Index classification was not statistically associated (p < .05) with demographic variables. Incidence (%) differs across demographic variables due to missing data.

Measures

Tinnitus Functional Index (TFI)

The TFI (Meikle et al., 2012) is used specifically for clinical trials in which tinnitus-associated symptom severity may change over time. The TFI is comprised of 25 questions forming eight subscales. Subscales include intrusiveness of tinnitus, sense of control, cognitive interference, sleep disturbance, auditory issues, relaxation issues, quality of life, and emotional distress. Individuals with TFI scores below 25 are classified as “mild tinnitus,” while scores between 25 and 50 are considered “significant problems,” and scores above 50 indicate severe tinnitus that warrants more intensive therapeutic approaches.

PTSD Checklist for DSM-5 (PCL-5)

The PCL-5 (Weathers et al., 2013) has excellent psychometric characteristics for screening and as an indicator of PTSD symptom severity (McDonald & Calhoun, 2010). The PCL-5 is a 20-item, self-report measure, selected for its dimensional sensitivity; higher scores reflect greater PTSD severity.

Procedure

All study procedures were approved by the Institutional Review Board at The University of Texas Health Science Center at San Antonio and complied with ethical standards of the American Psychological Association in the treatment of human research subjects. Participants who endorsed PTSD symptoms and posttraumatic headache were referred by VA providers and recruited through VA and Department of Defense specialty clinics. After providing informed consent, study staff scheduled participants to complete baseline measures, including the TFI and PCL-5, to determine study eligibility. Eligible participants were randomized to receive CBT, CPT, or TAU in a 1:1:1 ratio. The data analyzed for the present study included only baseline assessments.

Data Analytic Strategy

The primary aim of the present study was to examine the relationship between tinnitus-related distress and PTSD severity in a sample of veterans with confirmed PTH and PTSD symptoms. Frequencies (%) and means (M) with standard deviations (SD) were calculated to describe the nature of tinnitus-related distress and PTSD symptom severity at the baseline assessment. Pearson’s zero-order correlations (r) were used to evaluate the magnitude and direction of associations between the tinnitus-related distress and PTSD severity as measured by the TFI and PCL-5, respectively. Finally, we completed one-way analysis of covariance (ANCOVA) with a Sidak adjustment for multiple comparisons to examine PTSD symptom severity differences across the TFI classification categories: “mild,” “significant,” and “severe.” Head injury type, classified as “blast,” “blunt,” and “both,” was entered into the model as a covariate to determine if the relationship between TFI and PTSD varied as a function of head injury mechanism. Cohen’s d effect sizes were calculated to describe the nature of significant pairwise comparisons. A Cohen’s d of 0.20, 0.50, and 0.80 can be interpreted as a small, medium, and large effect, respectively (Cohen, 1988). Analyses were completed in R Version 4.0.2 (R Core Team, 2017).

Results

At baseline, participants demonstrated elevated tinnitus-related distress on the TFI total score (M = 50.80, SD = 21.89), with scores ranging from 0–97. Approximately, 49.5% of participants scored in the “severe” range (50 or greater), 39.3% reported “significant problems” with tinnitus (TFI = 25–50), and 10.7% of the sample reported “mild” tinnitus impairment (TFI =1–25). On the PCL-5, 82.1% of participants had a probable PTSD diagnosis. On average, participants scored 47.00 (SD = 14.93) on the PCL-5, which is above the recommended cutoff of 33 for a probable PTSD diagnosis (Blevins et al., 2015). Zero-order correlation results were used to evaluate the relationship between tinnitus-related distress and PTSD severity based on the TFI and PCL-5 total scores and subscale scores, respectively. Greater TFI total severity was related to greater PTSD total severity (r (11 2) = .39, p < .001). Greater scores on all TFI subscales were associated with greater reexperiencing symptoms on the PCL-5 (r = .20 to r = .44; Table 2). Additionally, greater scores on the TFI subscales, with the exception of sleep, were associated with greater levels of avoidance symptoms (r = .19 to r = .27). Problems with tinnitus-related intrusions, hearing, relaxation, quality of life, and emotion were related to greater levels of negative mood/cognitions and hyperarousal (r = .23 to r = .38). See Table 2 for correlations between the TFI and PCL-5.

Table 2.

Associations Between PTSD Symptom Severity and Tinnitus-Related Distress Subscales

M SD 1 2 3 4 5 6 7 8 9 10 11 12
1. PCL B 11.21 4.33 1.0
2. PCL C 5.44 2.17 .59** 1.0
3. PCL D 15.39 6.27 .74** .62** 1.0
4. PCL E 14.96 4.31 .69** .53** .70** 1.0
5. Intrusive 60.00 26.47 .31** .21* .24* .23* 1.0
6. Control 61.56 23.92 .20* .19* .16 .18 .53** 1.0
7. Cognitive 56.90 24.99 .32** .20* .17 .17 .61** .47** 1.0
8. Sleep 46.99 29.41 .32** .17 .17 .17 .57** .36** .56** 1.0
9. Hearing 52.32 25.82 .39** .19* .29* .31** .69** .46** .58** .57** 1.0
10. Relax 51.28 28.63 .44** .22* .37** .38** .72** .48** .59** .59** .73** 1.0
11. QOL 42.34 28.44 .41** .22* .32** .34** .57** .36** .64** .70** .74** .74** 1.0
12. Emotion 38.10 28.59 .41** .27* .30** .31** .60** .37** .58** .64** .62** .69** .79** 1.0
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Note. PTSD = posttraumatic stress disorder; PCL = PTSD Checklist for DSM-5; PCL B = PCL reexperiencing subscale; PCL C = PCL avoidance subscale; PCL D = PCL mood and cognitions subscale; PCL E = PCL hyperarousal subscale; QOL = PCL quality of life subscale. Bordered estimates are the correlations between PTSD severity and tinnitus subscales.

**

p < .001

*

p < .05.

One-way ANCOVAs were conducted to determine if PTSD total severity and PTSD subscale severity differed across the tinnitus functional impairment classification groups controlling for head injury type. There were significant differences on PTSD total severity (F(2, 108) = 6.52, p = .002), reexperiencing (F(2, 108) = 8.26, p < .001), negative mood/cognitions (F(2, 108) = 4.37, p = .02), and hyperarousal (F(2, 189) = 4.58, p = .01). Avoidance was the only PTSD subscale that did not significantly differ across the tinnitus classifications (F(2, 108 = 3.04, p = .052). As seen in Table 3, Sidak post hoc analyses revealed that participants with severe tinnitus impairment had significantly greater PCL-5 total scores compared to participants whose tinnitus impairment was mild (Mdiff = 15.12, SE = 4.55, p = .004). Participants with severe tinnitus impairment also had significantly greater reexperiencing symptoms compared to participants with significant (Mdiff = 2.60, SE = 0.84, p = .008) and mild tinnitus (Mdiff = 4.45, SE = 1.31, p = 003). Furthermore, those with severe tinnitus demonstrated greater negative mood/cognitions (Mdiff = 5.29, SE = 1.95, p = .02), and hyperarousal (Mdiff = 3.87, SE = 1.33, p = .02) severity compared to those with mild tinnitus impairment. Effect size differences ranged from large (d = 0.89) to very large (d = 1.54) across significant post hoc analyses (Table 3).

Table 3.

PTSD Severity Differences by Tinnitus Related Distress Classification

Baseline PTSD Severity × TFI Classification Sidak Post Hoc Mean Differences
1. Severe 2. Significant 3. Mild 1 vs. 3 1 vs. 2 2 vs. 3
M SD M SD M SD Mdiff d Mdiff d Mdiff d
PCL Total 51.60 14.46 44.64 13.88 36.08 13.52 15.52** 1.57 6.96* 0.69 8.55** 0.88
PCL B 12.78 4.20 10.11 3.84 8.25 4.16 4.53** 1.53 2.67** 0.95 1.86 0.66
PCL C 5.78 2.00 5.5 2.11 4.08 2.28 1.70* 1.12 0.28 0.19 1.41 0.91
PCL D 17.02 6.11 14.59 5.76 11.67 6.71 5.35* 1.18 2.43 0.58 2.92 0.66
PCL E 16.02 4.10 14.43 4.42 12.08 3.53 3.94* 1.43 1.59 0.53 2.35 0.83
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Note. Tinnitus classification: Mild = < 24; Significant = 25–50; Severe = 51 <; PTSD = posttraumatic stress disorder; TFI = Tinnitus Functional Index; PCL = PTSD Checklist for DSM-5; PCL B = PCL reexperiencing subscale; PCL C = PCL avoidance subscale; PCL D = PCL mood and cognitions subscale; PCL E = PCL hyperarousal subscale.

**

p ≤ .005

*

p < .05

Discussion

This study evaluated the relationship between tinnitus-related distress and symptoms of PTSD among a treatment-seeking sample of veterans with posttraumatic headache. Findings support prior research suggesting particularly deleterious functional outcomes among individuals with comorbid tinnitus and PTSD (Fagelson, 2007; Fagelson & Smith, 2016). The correlational analyses indicated that increased intrusiveness of tinnitus—including the perceived loudness, awareness, and annoyance—was significantly related to increases in PTSD symptom clusters, including reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Similarly, increases in (1) auditory difficulties related to tinnitus, (2) difficulties with relaxation, (3) reduced quality of life, and (4) emotional distress were related to increased reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Increased cognitive interference was related to increased reexperiencing and avoidance, while sleep disturbance was only related to increased reexperiencing symptoms of PTSD. Results are consistent with neurobiological evidence that suggests commonly altered brain networks between individuals with PTSD and tinnitus. Dysregulated brain regions within the auditory vigilance network among veterans with combat PTSD (Vanasse et al., 2019) overlap with alterations found among individuals with tinnitus (De Ridder et al., 2014; Husain, 2016; Lv et al., 2017, 2018; Pattyn et al., 2016).

Severity of PTSD also was related to the aspects of well-being related to tinnitus. Participants who were classified as having a “severe” impact due to their tinnitus had significantly heightened PTSD symptoms of reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity compared to individuals classified as having “significant” or “mild” tinnitus-related distress. Additional analyses conveyed that only the avoidance cluster of PTSD changed as a function of the mechanism of head injury (e.g., blast, blunt, or both) and not tinnitus-related distress. Overall, clinicians should consistently measure the impact of tinnitus and assess the potential barriers to therapy related to tinnitus-related distress. A more thorough assessment can help clinicians distinguish between symptoms due to type of head injury, psychological trauma, tinnitus, and how symptoms may bidirectionally influence one another.

Prior randomized controlled trials that examined the efficacy of PTSD therapies (e.g., Foa et al., 2018, 2019; Resick, Wachen et al., 2017; Resick et al., 2015) did not assess for the presence or functional impairment of tinnitus. Given the significant relationship between the two disorders, it is possible that co-occurring tinnitus could have contributed to failure of PTSD to abate, or for improvement in tinnitus-related distress. Among patients with both disorders, a more thorough assessment is warranted to determine whether avoidance (e.g., incompletion of assignments, missing or canceling appointments) and alterations in arousal and reactivity (e.g., sleep disturbance, irritability, hypervigilance) are a function of tinnitus or PTSD. Negative alterations in cognition and mood and reexperiencing should also be assessed to discern whether specific symptoms are due to tinnitus or PTSD. Challenging treatment-interfering cognitions related to tinnitus may improve retention rates and treatment outcomes.

PTSD treatment dropout rates may also be improved by incorporating skills training and behavioral techniques related to the management of tinnitus. It is possible that individuals with PTSD and comorbid tinnitus require additional therapeutic options in order to simultaneously address both conditions, or they may benefit from a sequenced approach that targets either PTSD or tinnitus first. Therapies such as cognitive-behavioral therapy for tinnitus distress are reasonably effective (Cima et al., 2014; Hesser et al., 2011). Mindfulness-based therapies also suggest promise when applied to individuals with tinnitus (McKenna et al., 2018).

This study is not without limitations. First, although the correlational analyses provide valuable information concerning the relationship between tinnitus and PTSD, it is still unknown whether the relationship is unidirectional or bidirectional. We also do not have a comprehensive understanding of the nature of the tinnitus for each participant, whether the tinnitus was unilateral or bilateral, the source of the tinnitus (e.g., combat or training occupational exposures, TBI, ototoxic medications), or the duration of the tinnitus. Additionally, it is difficult to determine how posttraumatic headache influenced participants’ symptomatology. Given that the parent study recruited individuals with posttraumatic headache, there is a restriction of range within the sample that limits the interpretation of the results. A final limitation is that the current study did not include a comparative sample of individuals with PTSD alone. Future research should investigate symptom severity differences between those with and without tinnitus and comorbid PTSD.

To the best of our knowledge, this is the first study to delineate the relationships among factors of tinnitus-related distress and symptom clusters of PTSD. Results demonstrate a strong relationship between the two disorders. Future research should examine whether alleviation of either tinnitus-related distress or PTSD would result in alleviation of symptoms of the other disorder. Furthermore, clinicians should assess and monitor tinnitus and related distress, especially when working with active duty service members and veterans.

Acknowledgments

This research was supported by Consortium to Alleviate PTSD award numbers W81XWH-13-2-0065 from the U.S. Department of Defense, Defense Health Program, Psychological Health and Traumatic Brain Injury Research Program (PH/TBI RP), and I01CX001136-01 from the U.S. Department of Veterans Affairs, Office of Research & Development, Clinical Science Research & Development Service. We would like to thank Juan Carlos Aguilera, Antoinette Brundige, Deanne Hargita, Clara Stiefel, Rachel Rosenfield, Daisy Rodriguez, Suheily Valderrama, Nicole Brackins, and Adrianna Cole for their research support on this project.

Footnotes

This study was registered with ClinicalTrials.gov (Identifier NCT02419131). The authors report no known conflicts of interest. The views expressed herein are solely those of the authors and do not reflect an endorsement by or the official policy or position of the Department of Veterans Affairs, the Department of Defense, or the U.S. Government. The funding sources were not involved in the study design, the collection, analysis and interpretation of data, the writing of this report, or the decision to submit this article for publication.

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