Conceptual framework for tinnitus: a cognitive model in practice

Tinnitus is a conscious attended awareness perception of sourceless sound. Widespread theoretical and evidence-based neurofunctional and psychological models have tried to explain tinnitus-related distress considering the influence of psychological and cognitive factors. However, tinnitus models seem to be less focused on causality, thereby easily misleading interpretations. Also, they may be incapable of individualization. This study proposes a Conceptual Cognitive Framework (CCF) providing insight into cognitive mechanisms involved in the predisposition, precipitation, and perpetuation of tinnitus and consequent cognitive-emotional disturbances. The current CCF for tinnitus relies on evaluative conditional learning and appraisal, generating negative valence (emotional value) and arousal (cognitive value) to annoyance, distress, and distorted perception. The suggested methodology is well-defined, reproducible, and accessible, which can help foster future high-quality clinical databases. Perceived tinnitus through the perpetual-learning process can always lead to annoyance, but only in the clinical stage directly cause annoyance. In the clinical stage, tinnitus perception can lead indirectly to distress only with experiencing annoyance either with (“\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\underset{{\mathcal {C}}}{{{\varvec{Ind-1}}}}}$$\end{document}Ind-1C” = 1.87; 95% CI 1.18–2.72)[“1st indirect path in the Clinical stage model”: Tinnitus Loudness \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\rightarrow$$\end{document}→ Attention Bias \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\rightarrow$$\end{document}→ Cognitive-Emotional Value \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\rightarrow$$\end{document}→ Annoyance \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\rightarrow$$\end{document}→ Clinical Distress]or without (“\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\underset{{\mathcal {C}}}{{{\varvec{Ind-2}}}}}$$\end{document}Ind-2C”= 2.03; 95% CI 1.02–3.32)[ “2nd indirect path in the Clinical stage model”: Tinnitus Loudness \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\rightarrow$$\end{document}→ Annoyance \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\rightarrow$$\end{document}→ Clinical Distress] the perpetual-learning process. Further real-life testing of the CCF is expected to express a meticulous, decision-supporting platform for cognitive rehabilitation and clinical interventions. Furthermore, the suggested methodology offers a reliable platform for CCF development in other cognitive impairments and supports the causal clinical data models. It may also enhance our knowledge of psychological disorders and complicated comorbidities by supporting the design of different rehabilitation interventions and comprehensive frameworks in line with the “preventive medicine” policy.


Model Definition Clinical Evidence
Most tinnitus experiences do not complain about it [18], but tinnitus sufferers more persistently perceive tinnitus than others.

Hallam et al.
( proposed that failure in habituation to tinnitus causes increased awareness because of negative appraisal and emotional significance. Tolerance for the tinnitus symptom is a function of time since onset Hazell (1979) and [87], and it diminishes by stress, worry, and comorbidities.
Complaint behaviour showed no relationship with perceived loudness of tinnitus [33].
Tinnitus severity and its impact on life reveal no correlation with its psychoacoustic parameters [43,48].
Non-auditory systems are responsible for the tinnitus severity and annoying level.[58] The majority (94%) of participants of the soundproof room experiment after 5 minutes heard sounds similar to those described by tinnitus sufferers, which disappeared after they left the room [47] Tinnitus with normal hearing was documented in 20% of patients [21], and almost 27% of totally deafened people do not experience tinnitus [40].
About 40% of tinnitus patients showed increased sensitivity levels to environmental sound.[42,56] Jastreboff et al. ( classical conditioning was proposed as the principal mechanism behind the aversive emotional states of tinnitus.
Tinnitus incident was reported twice in a hearing-impaired population versus normal hearing [19].Concurrently, 20% of tinnitus sufferers have normal hearing [21], and almost 27% of totally deafened people do not experience tinnitus [43].
No specific pattern was observed in tinnitus population audio-

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Investigator Model Definition Clinical Evidence
The majority of tinnitus experiences can naturally habituate to it [21,70].Habituation leading to ignoring tinnitus's presence since they consciously attend to tinnitus [82].
Tinnitus affects sleep and is particularly intense in preventing the continuation of sleep [71].
Clinically More catastrophic [15,85] thoughts negatively correlated with quality of life [93] and positively correlated with tinnitus severity.

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Investigator Model Definition Clinical Evidence
Anxiety sensitivity significantly predicts tinnitus distress, and high levels of trait anxiety were observed among patients with tinnitus [35].
Patients in the clinical tinnitus stage experience psychiatric disorders in their lifetime, particularly anxiety and depression [66,105,106].

McKenna et al.
( proposed the Cognitive Behavioral

Model of Tinnitus
Psychological therapies, specifically CBT for tinnitus, revealed a significant and sustained positive effect on tinnitus-related annoyance and distress [5,51,67].
People with tinnitus are weaker in executive control of attention but not selective attention processing [4,46,78,83].Tinnitusrelated annoyance was revealed to be highly correlated to selfreported inability to ignore tinnitus [52].Patients seeking tinnitus the treatment reported being aware of their tinnitus more frequently [92].
Negative tinnitus experience was more correlated with lower quality of life [15,90].

A significant positive correlation was reported between Tinnitus
Vigilance and awareness [15].
Avoidance behavior is connected to more distressing tinnitus [50], like avoiding silence due to fear of cope incapability [65,84].
Auditory perception occurs in the absence of auditory input.
It has been shown that more than 80% of people with normal hearing can perceive phantom sounds in a soundproof room [11].

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Investigator Model Definition Clinical Evidence
In perception without awareness, the subject does not consciously identify it or even detect its presence [24].
Tinnitus perception is not just a sound percept, but it also includes affective components intimately linked to the sound percept due to the deafferentation of auditory input [8,37].
As a result of auditory deafferentation, the amount of information necessary to make sense of the world by the brain is limited [23].
De Ridder et al. ( Proposed an integrative model of auditory phantom perception: Tinnitus as a unified percept of interacting separable subnetworks.
Loudness perception occurs due to a dysfunctional noisesuppressing mechanism that is probably limbically driven [64,76].
Anatomically [80] and functionally [74], the auditory cortex is altered in people with tinnitus.
More than an exclusive focus on the auditory cortex is required to understand tinnitus in a clinically relevant sense.We need to consider the importance of distributed networks [27].
The cognitive disruption caused by tinnitus might be a starting point for later conditioned emotional reactions to tinnitus [3,73].
Cognitive inefficiency in tinnitus patients is related to the control of attentional processes [37].

McKenna (2006)
A model of the road to annoyance via different levels of cognitive functioning.
There are two forms of distressed tinnitus patients: one characterized by depression and the other by anxiety [28].
One problem with all self-report instruments, known as "negative affect", is that they are liable to confound general distress with specific complaints [95].

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Investigator Model Definition Clinical Evidence
Tinnitus often requires specialist consultation, and longitudinal data suggest that the rate of spontaneous improvement is low [7].
The bottom-up selective attention processes support the suppression of irrelevant stimuli, which may occur at the early stages by the TRN along the "lateral inhibition mechanism" [60,104].
Lateral inhibition ideally suppresses the noise originating from distracters and facilitates the processing essential stimuli.The amygdala, posterior orbitofrontal cortex, and mediodorsal thalamus ending at the Thalamic reticular nucleus may suppress the signal of distracting stimuli at sensory cortices [103].

Neurofunctional Tinnitus Model
The decline of the vmPFC inhibitory output revealed a reduction in gray matter in vmPFC, leading to increased activity of NAc [79,89].
The relevance of stimulus requires an active associated neuronal network to indicate its corresponding value or reward outcome in a particular context, called the "self-control" process [59].
The top-down relevant (cognitive emotional valued) signal can reach the attentive processes whereby the signal can become aware or unaware [34].
The hippocampus structure is not necessarily involved in tinnitus generation; however, the paralimbic is involved in the generation of tinnitus [68,89].
Personality disorders include the potential triggers of tinnitus and available tinnitus managements and treatments leading to appraisals such as "tinnitus is detrimental to my health" or "now, I am becoming deaf" [101].
The Neurofunctional Tinnitus Model hypothesizes that the perception of sound fundamentally depends on the allocation of attentional resources via the frontal cortex, which in turn, depends on the cognitive-emotional value and the relevance of the phantom stimulus to the context [31,32].

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Investigator Model Definition Clinical Evidence
The ability to consciously report sensory inputs is theorized as the perception process.We propose to add more details to the model of distinction between awareness and attention [63,94].
Analogous to observations in chronic pain research, bothersome tinnitus is considered an illness rather than a disease [30,86].
The negative interpretation of the signal and related heightened autonomic arousal levels would lead to dysfunctional cognitive processing and, therefore, disrupt habituation [16].

Cima (2018)
Fear-avoidance model of chronic tinnitus Since the medical or pharmacological cure is unavailable [26,27], current theoretical frameworks have been explanatory on some level.The cognitive-behavioral treatments (CBT) for tinnitus have been shown to be effective in decreasing tinnitus distress, anxiety, and annoyance and improving daily life functioning [17].
The resulting treatment approaches have alleviated complaints leading to reports of occasional recovery to a satisfactory quality of daily life in many patients.
Conditioned fear responses elicited by the tinnitus sound cause the tinnitus becoming bothersome [55,57].
Mainly through negative cognitive misinterpretations of the tinnitus signal, distress and bodily arousal are provoked, leading to inaccurate evaluations of sensory activity and distorted perceptions [72].
Individuals perceiving the tinnitus signal are subject to automatic emotional and sympathetic responses.These symptoms are misinterpreted as harmful or threatening [15,61,72].
The merits of Cognitive Behavioural Treatments (CBT) for tinnitus have decreased tinnitus disability and distress for a large group of patients [50,54].
Fear-related safety-seeking behaviors were postulated to be crucial in explaining increased suffering in tinnitus patients.Evidence revealed that the tendency to avoid so-called 'unsafe' stimuli or events because of the tinnitus mediates the association between tinnitus severity and quality of life [98, 99].

CLINICAL EVIDENCE FOR CCF 8
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Investigator Model Definition Clinical Evidence
The fear of bodily sensations was strongly related to tinnitus distress, again fully mediated by tinnitus-related avoidance behaviours [50].
A fear-avoidance model for bothersome tinnitus [15,61] significant tinnitus usually emerges during a period associated with external emotional stress [41].Zenner & Zalaman (2004) postulated that tinnitus sensitization develops when perceiving sound is classified as noxious, fear-inducing, unpredictable, and might cause a sense of deficiency in coping and helplessness.Cognitive Desensitized Therapy revealed reduce in psychosomatic tinnitus burden and the daily observation time and an improvement in the quality of life [101].Negative thinking about tinnitus is an essential component of tinnitus distress.The deficiency of positive thoughts does not necessarily indicate negative thoughts in tinnitus [100].Tinnitus-related distress or handicap associated with tinnitus complaint reflects cognitive and behavioral aspects[36, 62].
Ware Jr, J. E. & Sherbourne, C. D. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection.Medical care, 473-483 (1992).94.Watanabe, M. et al.Attention but not awareness modulates the BOLD signal in the Psychological review 96, 234 (1989).96.Weise, C., Heinecke, K. & Rief, W. Biofeedback-based behavioral treatment for chronic tinnitus: results of a randomized controlled trial.Journal of consulting and clinical psychology 76, 1046 (2008).97.Weise, C. et al.The role of catastrophizing in recent onset tinnitus: its nature and association with tinnitus distress and medical utilization.International journal of audiology 52, 177-188 (2013).98. Westin, V., Hayes, S. C. & Andersson, G.Is it the sound or your relationship to it?The role of acceptance in predicting tinnitus impact.Behaviour research and therapy 46, 1259-1265 (2008).99.Westin, V. Z. et al.Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment of tinnitus: a randomised controlled trial.Behaviour research and therapy 49, 737-747 (2011).100.Wilson, P. H. & Henry, J. L. Tinnitus Cognitions Questionnaire: development and psychometric properties of a measure of dysfunctional cognitions associated with tinnitus.The international tinnitus journal 4, 23-30 (1998).101.Zenner, H. P., Pfister, M. & Birbaumer, N. Tinnitus sensitization: Sensory and psychophysiological aspects of a new pathway of acquired centralization of chronic tinnitus.Otology & neurotology : official publication of the American Otological