In a study by University of Maryland Medical Center physician-researchers, patients with pulsatile tinnitus (PT) perceived themselves to have a higher tinnitus handicap than unselected patients with central tinnitus, the type of non-rhythmic sound typically associated with hearing loss or noise injury. Despite this, levels of anxiety and depression for patients with PT did not scale in the manner of patients with severe central tinnitus. Those patients exhibited a stronger correlation between tinnitus severity and the severity of anxiety and depression than patients with PT.1

Earlier studies established tinnitus as a multifaceted disease that often correlates with psychiatric conditions, with more than 70% of the patients demonstrating associated emotional difficulties.2 This study aimed to further explore the difference between these two groups of patients who present with tinnitus, as non-pulsatile tinnitus (NPT or "central" tinnitus) generates in the brain's auditory pathways, whereas PT is a peripheral, mechanical phenomenon.1

"Our clinical impression was that anxiety and depression played a much greater, or at least a different, role in patients with central tinnitus than those with pulsatile tinnitus," said David Eisenman, MD, director of the Otology, Neurotology and Skull Base Surgery Program at the University of Maryland School of Medicine. "We designed this study to help test that impression and elucidate the nature of the relationship between psychiatric measures and tinnitus severity in these different groups."

The research team, led by Dr. Eisenman, published their work in The Laryngoscope. The prospective, cross-sectional study included patients 18 or older with a chief complaint of tinnitus who presented to a tertiary care otolaryngology and audiology outpatient practice from January to August 2021. The investigators divided study participants into three groups1:

  • Patients with PT, as determined by a single evaluating physician
  • Patients with NPT, as determined by the same physician
  • Patients with NPT self-referred to a tinnitus habituation program (THP) for advanced tinnitus care after having previously seen a physician for evaluation of their tinnitus

Before they visited with the physician, each patient took the 25-item tinnitus handicap inventory (THI), the seven-item general anxiety disorder scale (GAD-7), and the nine-item patient health questionnaire (PHQ-9). Median scores between groups and the correlation of scores within groups were calculated and compared.1

The researchers believe these findings offer significant implications for understanding the pathophysiology of these two distinct disorders and their treatment.1

  • Median THI scores were significantly higher for THP and PT patients than unselected NPT patients (58 and 44 vs. 20, p≤0.001).
  • Median GAD-7 (10 vs. 2.5 and 2, p≤0.001) and PHQ-9 (7 vs. 4 and 4, p=0.04) scores were highest in THP patients compared with PT and NPT.
  • The strongest correlation between tinnitus handicap and psychiatric measures was seen in THP patients.
Measure All Subjects (n=107) PT (n=40) Non-pulsatile tinnitus/THP (n=47) Non-pulsatile tinnitus/non-THP (n=20) p-value
THI median (IQR) 44 (49) 44 (49) 58 (370) 20 (13) <0.001
GAD-7 median (IQR) 4 (10) 2.5 (7) 10 (10) 2 (3.5) <0.001
PHQ-9 median (IQR) 5 (8) 4 (5.7) &7 (9) 4 (3.7) 0.04

All patients with tinnitus should be screened for anxiety and depression when appropriate, but in patients with NPT it is even more crucial since psychiatric comorbidities often drive up self-perceived tinnitus severity and handicap. They also note that while remaining attentive to treating anxiety and depression when appropriate, physicians should consider other tinnitus-specific treatments, such as cognitive behavioral therapy or sound therapy.1

Learn more about the University of Maryland Medical Center Department of Otorhinolaryngology, or call 1-800-373-4111 to refer a patient.


  1. Williams AP, Gourishetti SC, Flaherty MA, Eisenman DJ. Anxiety, Depression, and Symptom Severity in Patients with Pulsatile and Non-Pulsatile Tinnitus. The Laryngoscope. 2022. doi: 10.1002/lary.30238. Online ahead of print.
  2. Tyler RS, Baker LJ. Difficulties experienced by tinnitus sufferers. J Speech Hear Disord. 1983;48(2):150-154.