5Objectives: It is well established that catastrophic mis-interpretations and fear are involved in 6 the suffering and disability of patients with chronic pain. This study investigated whether 7 similar processes explain suffering and disability in patients with chronic tinnitus. We 8 hypothesized that patients who catastrophically (mis)interpret their tinnitus would be more 9 fearful of tinnitus, more vigilant towards their tinnitus, and report less quality of life. 10 Moreover, tinnitus-related fear was expected to act as a mediator in reduced quality of life. Tinnitus is the awareness of a sound without an external source. Several theories regarding its 26 pathophysiology exist of which the most advocated is the hypothesis that tinnitus occurs as a 27 result of spontaneous anomalous neural activity, coinciding with changes in the auditory 28 system at any level along the auditory axis. Tinnitus has been described as a phantom auditory 29 perception and the involvement of non-auditory structures are considered of key importance 30 in clinically relevant tinnitus complaints (Cacace, 2003; Jastreboff, 1990; Jastreboff & Hazell, 31 1993).
32The larger part of individuals experiencing chronic tinnitus eventually habituates or 33 adapts to the tinnitus sound and is able to function fairly well. Only a small part (5-8 %) of 34 this group tinnitus remains distressing and disabling (Ahmad & Seidman, 2004). In 35 individuals with persistent tinnitus complaints, the acoustical characteristics of the tinnitus 36 (e.g. loudness or pitch) is not univocally related to the severity of the tinnitus or treatment 37 outcome (Jastreboff, 1990; Jastreboff & Hazell, 1993). Only a weak relationship can be 38 established between perceived psycho-acoustic characteristics of the tinnitus (e.g. loudness or 39 pitch) and the severity of complaints. In chronic tinnitus, the interpretation of the sound might 40 be more important in defining the severity of complaints than the sound itself (Andersson, 41 2003; Henry & Meikle, 2000; Hiller & Goebel, 2007; Jastreboff & Hazell, 1993 Heuts, & Lysens, 1999; Rief & Broadbent, 2007). 56 Given the analogies between chronic tinnitus and chronic pain (Folmer, Griest, & 57 Martin, 2001; Tonndorf, 1987), the current study is an attempt to apply a cognitive (Sullivan, Kues, & Mayhew, 1996). Pain related fear can be defined as the fearful reactions 72 towards pain and pain-related activities and fear of (re)injury, including fearful beliefs about 73 causes of pain. The FA model predicts that if pain is misinterpreted catastrophically, it will 74 4 elicit specific pain-related fear associated with safety behaviours. These behaviours may be 75 functional in the short-term as fear is decreased, but paradoxically they worsen the problem in 76 the long run, because of disuse and increased disability.
77The importance of pain-related fear in the development of pain-related disability has 78 been previously established as being pivotal in the development of pain-related disa...