Modern Psychological Studies

Volume 18 Number 2 Article 13

2013

Distress tolerance and mental health outcomes

Carrie A. Stemke Simmons College

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Recommended Citation Stemke, Carrie A. (2013) "Distress tolerance and mental health outcomes," Modern Psychological Studies: Vol. 18 : No. 2 , Article 13. Available at: https://scholar.utc.edu/mps/vol18/iss2/13

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Distress Tolerance and Mental Health Outcomes

Carrie A. Stemke

Simmons College

Abstract This literature review has compiled research on two related subjects: the construct of distress tolerance and the treatment of mental health issues for which low distress tolerance is an underlying factor. The purpose of this work is to not only examine a central mechanism in the onset and maintenance of select psychopathologies, but also to examine ways in which treatment focused on raising an individual's distress tolerance can help in symptom reduction. This review also proposes that a better understanding of stress and an individual's reaction to it can lead to both more effective treatment and towards the future fulfillment of two goals: the mitigation of the symptoms and effects of a mental health disorder, and the prevention of the onset of stress-related psychopathologies.

Introduction reducing the instance of severe mental health disorders. There is considerable variability in each of our experience of and response to stress. This review has three goals, and in order Such variability may be conceptualized as to achieve them, the information in this an individual's level of distress tolerance-in review has been organized into three main layman's terms, one's " threshold." sections. First, the construct of distress Distress tolerance may be defined as an tolerance will be addressed: it will be individual's ability to experience and defined, and related constructs will be tolerate negative psychological states described. Second, psychopathologies that (Leyro, Zvolensky, & Bernstein, 2010; may be conceptualized as related to distress Simons & Gaher, 2005). Distress tolerance tolerance will be addressed. For the has long been a focus and interest of purposes of brevity and clarity, three professionals in the field of psychology, in specific mental health disorders have been part because it is thought to be a major chosen for examination: Posttraumatic contributor to the development and Stress Disorder (PTSD), Borderline maintenance of various psychopathologies, (BPD), and Substance including substance abuse and personality Use Disorders. After a description of each disorders (Leyro et al., 2010). But what is disorder has been provided, the role of the exact nature of the relationship between distress tolerance in each of those disorders distress tolerance and the development of will be reviewed and the implications for psychopathology? The importance of the treatment will be discussed. Third, and relationship certainly cannot be denied: finally, future issues and possible directions estimates of the prevalence of mental health for research will be presented. disorders suggest that approximately 30% of adults in the United States suffer serious The Construct of Distress Tolerance mental health issues that require treatment by a clinician (Corner, 2008). It is a Despite widespread interest in distress generally accepted theory that personality tolerance, and particularly its relevance to has an effect on an individual's level of mental health, there has been considerable distress tolerance. The exact mechanisms debate among researchers over the proper behind this relationship are an area worthy way to define the nuances of this construct; of close study in order to apply the some members of the field viewed the focus knowledge to teaching better stress-coping of distress tolerance as somatic, while others skills, the effects of which are unknown in

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believed the focus to be emotional (Leyro et constructs to substance abuse. For example, al., 2010). in one study, individuals with lower anxiety sensitivity were more likely to use marijuana Distress tolerance is a variable construct in order to conform to their peers, while reflecting the ability-or lack thereof-of an individuals with lower distress tolerance individual to both tolerate stressful states used marijuana in order to cope with and to persist at completing goal-oriented negative (Zvolensky, Marshall, tasks while experiencing distress (McHugh, Johnson, Hogan, Bernstein, & Bonn-Miller, et al., 2011). Distress tolerance can be 2009). broadly viewed as having two components. The first is an internal component, or the Distress Tolerance and Psychopathology individual's perceived ability to withstand negative emotions and other aversive states, The construct of distress tolerance is such as uncomfortable bodily sensations highly relevant to our understanding of a (Leyro et al., 2010). The second is an range of psychopathologies and mental external component, which focuses on the health disorders. To illustrate this concept, individual's actual behavioral response to the following sections of this review will those emotions or states (Leyro et al., 2010). focus on Posttraumatic Stress Disorder, Viewed as a dimensional "trait," those Borderline Personality Disorder, and higher in distress tolerance are more likely Substance Use and Dependence and their to be able to process and approach negative individual relationships with distress emotions and other aversive states, while tolerance. those lower in distress tolerance are more likely to fear those emotions and respond Posttraumatic Stress Disorder maladaptively by attempting to avoid or escape negative emotions and aversive states Posttraumatic Stress Disorder (PTSD) (Leyro, et al., 2010). Distress tolerance is belongs to the category of stress disorders. theorized as affecting an individual's In keeping with DSM-IV-TR diagnostic perception of and response to both somatic criteria for PTSD, clients who are and emotional states (Leyro et al., 2010). determined to be suffering from the disorder must have experienced or observed a At first glance, distress tolerance may traumatic event in which the threat of death seem to overlap with anxiety; one might say or grievous physical injury to their own that those low in distress tolerance are person or to others was present, and the "anxious" about negative emotions and individual's response to that event must be aversive states, while those high in distress discovered to have been one of devastating tolerance are not. However, research by fear or powerlessness (APA, 2000). In the Keough and colleagues (2010) demonstrated event that the client meets both of these that while distress tolerance is uniquely criteria, the clinician will explore the associated with an increased vulnerability to existence of specific identifying symptoms panic, worry, have social anxiety, and to be which include but are not limited to: obsessive compulsive, it is not inextricably recurrent, intrusive, and distressing linked with the anxiety disorders recollection of the trauma, acting or feeling themselves. There is also a marked as though the trauma is happening again, difference between anxiety sensitivity and and intense psychological and physiological distress tolerance in studies relating the two distress at exposure to either internal or

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external cues that represent a characteristic Vujanovic, Bonn-Miller, Bernstein, & of the traumatic event that occurred (APA, Zvolensky, 2010). Scores from the Distress 2000). The individual must also be Tolerance Scale (Simons & Gaher, 2005) persistently avoiding stimuli associated with were significantly related to PTSD symptom trauma, as well as conversations, thoughts, severity, even when variance caused by or activities that might remind the victim of participant sex, number of traumatic events, the traumatic event (APA, 2000). The range and trait-level neuroticism were accounted of symptoms associated with PTSD contains for (Marshall-Berenz et al., 2010). The both maladaptive physiological and results of this study suggest that an psychological features. Individuals have individual's self-efficacy may at least in part difficulty with symptoms ranging from explain their level of distress tolerance and feeling detached from others to outward their behavior in the face of a stressful event bursts of anger and hyper-vigilance (APA, or (Marshall-Berenz et al., 2010). 2000). The DSM-IV-TR asserts that In other words, an individual's perception of symptoms must last for more than one their own ability to manage stress often month to receive a diagnosis of PTSD, and affects their actual behavior. Therefore, that the disturbance is such that it individuals who are not confident in their significantly impairs functioning in ability to tolerate stress may be more likely important areas of life (APA, 2000). to attempt to avoid the aversive state or event, which would in turn feed a vicious Low distress tolerance plays a cycle of negative reinforcement (Marshall- significant role in the maintenance of the Berenz et al., 2010). symptoms of PTSD, which has been characterized as a disorder of emotional and Consequently, therapies for PTSD have situational avoidance (Foa & Kozak, 1986). been specifically focused on reducing an Trauma places enormous emotional individual's level of anxiety in order to demands upon its victims: not only are the better enable the person to cope with stress. symptoms perceived as threatening to the Skills such as relaxation training and individual, but tolerating the meditation have been taught to individuals psychopathological aftereffects of trauma with stress disorders to both support more requires tremendous emotional regulation efficient stress management and also to (Keane & Barlow, 2002). decrease the negative psychophysiological effects of stress (Kabat-Zinn, 1990; Stetter There is empirical evidence to suggest & Kupper, 2002). The use of antianxiety that low distress tolerance enhances and medications and antidepressants have also worsens PTSD symptoms. For example, the been effective in helping to control the results of a study that examined a group of tension, nightmares, and flashbacks often trauma-exposed nonclinical adults found experienced by individuals with PTSD that low distress tolerance was incrementally , (Comer, 2008). Finally, exposure therapy, correlated with increasingly severe PTSD which has been suggested by some studies symptoms (Vujanovic, Bonn-Miller, Potter, to be the most effective intervention for Marshall, & Zvolensky, 2011). Specifically, PTSD, has been utilized to help the evidence was found that suggests that one's individual not only recognize the cause of perceived ability to withstand emotional their , but also to "attack" them distress may be related to the severity of (Turner, Beidel, & Frueh, 2005; Wiederhold PTSD symptoms (Marshall-Berenz, & Wiederhold, 2005). The recent research

129 MPS I Distress Tolerance & Mental Health Outcomes I Stemke I Pg. 127-136 on the role of distress tolerance in PTSD disorder is the persistent inability and adds weight to the efficacy of these anxiety- unwillingness to tolerate emotional distress. reducing therapies and suggests that not only Such a lack of distress tolerance leads to a has a central underlying mechanism to the destructive cyclical relationship in which the disorder been recognized and focused upon, negative experiences that the individual has but that clinicians are aware that assessing encountered brings about a reaction that an individual's level of distress tolerance is leads to further dysfunction in interpersonal key to understanding the severity of their relationships, chronic frustration, and a PTSD symptoms. marked difficulty coping with stressors (Linehan, 1987). There is empirical Borderline Personality Disorder evidence to support this perspective. For example, a 2009 experiment adapted a Borderline Personality Disorder (BPD) measure of distress tolerance and examined is characterized by pervasive instability in its relationship with emotion dysregulation mood, self-image, interpersonal amongst a group of 35 outpatients receiving relationships, and impulsivity (Leichsenring, therapy: 17 of those subjects had BPD, Leibing, Kruse, & Leweke, 2011). Although while 18 did not (Gratz, Rosenthal, Tull, the causes of the disorder are not clear, Lejuez, & Gunderson, 2009). The research suggests that stressful life events, researchers specifically defined emotion such as divorce of parents, or physical or dysregulation as the unwillingness to sexual abuse, can contribute to the onset of experience distress in order to pursue goal- BPD (Leichsenring et al., 2011). High rates oriented activities as well as the inability to of comorbid mental disorders and engage in goal-oriented activities when often accompany BPD, as well as other self- experiencing distress (Gratz, et al. 2009). destructive behaviors like self-harm Although the BPD patients were less willing (Leichsenring et al., 2011). The DSM-IV-TR than their study counterparts to experience has determined that the symptoms of BPD distress in order to engage in goal-oriented include, but are not limited to: persistently behavior, they did not show greater unstable self-image, emotional instability difficulty engaging in goal-oriented caused by difficulty regulating emotions, activities while experiencing distress (Gratz, and intense, unstable interpersonal et al. 2009). These results offer two relationships characterized by a cycle of important pieces of evidence: first, that low extreme idealization and extreme distress tolerance does indeed affect the devaluation (APA, 2000). manner in which individuals with BPD make decisions, and that those decisions are Marsha Linehan's research on BPD and usually avoidant of stress and second, that subsequent development of Dialectical individuals with BPD are capable of Behavior Therapy (DBT) for those patients experiencing stress in order to pursue goal- is one of the strongest existing examples of a directed behavior. disorder characterized by distress tolerance and an effective therapy specifically This last piece of evidence suggests that grounded in adjusting an individual's ability a therapy like DBT, which actively helps to tolerate distress. BPD patients learn how to cope with their intolerance of distress, is extremely useful in Linehan's work (1993) on BPD suggests allowing individuals with low distress that an underlying central mechanism of this tolerance to more effectively manage the

130 MPS I Distress Tolerance & Mental Health Outcomes I Stemke I Pg. 127-136 experiences that might upset them (Linehan, it is both an outcome, as a psychopathology 1993). DBT also focuses on the behavioral that can develop from low distress tolerance, outcome of a negative response to stress by and a coping mechanism for individuals providing alternative methods to interpret with low distress tolerance. and react to stressful situations (Linehan, 1993). It is this twofold model: helping to The use of and subsequent dependence increase distress tolerance and creating more on drugs is one method of emotional coping, effective behavioral responses to stress that and the rapid alleviation of negative have made DBT a treatment of choice in psychological states is likely to be appealing treating BPD. Finally, the study from Gratz to individuals low in distress tolerance and colleagues (2009) demonstrates that a (Simons & Gaher, 2005). Research has person's level of distress tolerance can demonstrated that distress tolerance is change, which further supports the idea that negatively correlated with alcohol and including therapy geared towards marijuana use and that the relationship is accomplishing that change is an integral part incremental (Simons & Gaher, 2005; of treatment in a disorder where distress Zvolensky et al., 2009). In other words, tolerance plays a central role. individuals with low distress tolerance reported a stronger need to use drugs like Substance Abuse and Dependence alcohol or marijuana to tolerate negative emotional states, and that as distress Substance abuse and dependence have tolerance decreased, substance use the same initial basis for diagnosis: both are increased. defined by the DSM-IV-TR as a harmful pattern of substance use that leads to Research has also shown evidence of an significant impairment (APA, 2000). Each association between distress tolerance and has different features that result in the problems with substance use. When Simons specific diagnosis. Substance abuse involves and Gaher (2005) examined the relationship recurrent use of drugs that results in a failure between distress tolerance and alcohol- to fulfill major obligations (e.g. at work, related problems in a new study, they found home, or school), recurrent drug-related a small but significant association between legal problems, and recurrent use of the drug distress tolerance and alcohol-related despite physically dangerous circumstances problems (Simons & Gaher, 2005). There (APA, 2000). Substance dependence is was no association between distress hallmarked by persistent need for the drug tolerance and the frequency with which an or unsuccessful efforts to control use, individual used alcohol, but there was a considerable time spend obtaining, using, or gender difference: distress tolerance recovering from the drug, the use of which predicted alcohol-related problems for men, has replaced important activities, and taking but not for women (Simons & Gaher, 2005). unintentionally larger doses of the drug over In a related study, Howell and colleagues a longer period of time (APA, 2000). Both (2010) found that both low distress tolerance disorders involve the continuing use of the and a sensitivity to anxiety predicted drug despite the pattern of use causing or problems with alcohol use; distress tolerance increasing social problems (APA, 2000). in particular was related to the use of alcohol as a coping mechanism. Daughters and Substance abuse and dependence plays colleagues (2008), found that substance an interesting dual role in distress tolerance: users with Antisocial Personality Disorder

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had lower levels of distress tolerance than 1996), and the dropout rate is staggeringly substance users without the disorder, which high for long-term residential programs further suggests that maladaptive behaviors (Substance Abuse and Mental Health like substance abuse stem from unhealthy Services Administration, 2002). Rather, it attempts to avoid negative emotions and was an individual's ability to withstand experiences, such as the difficulties negative emotional states that seemed to associated with living with Antisocial predict their length of survival in the Personality Disorder. These results strongly program. Specifically, the study examined connect to the idea that individuals low in the likelihood of treatment dropout as distress tolerance are likely to seek predicted by a variety of self-report immediate rewards, such as dispelling measures, including the Positive and negative emotions with illegal substances, Negative Affect Scale (PANAS), and and to continuously attempt to avoid performance on four stressful tasks, which unpleasant experiences (Leyro et al., 2010). included two psychological stressors (a mirror-tracing task and a paced auditory The construct of distress tolerance has serial addition task), and two physical relevance for the treatment of substance use stressors (a breath holding task and a cold and dependence. A key component pressor task) (Daughters et al., 2005). underlying the maintenance of substance use and dependence is the individual's That the researchers chose to study both intolerance for emotional and somatic physical and psychological stressors is sensations (Baker, Piper, McCarthy, evidence of a well-thought-out study: Majeskie, & Fiore, 2004). When applied to individuals at a drug rehabilitation facility rehabilitation for drugs, the idea is sensible: are likely to encounter both the physically withdrawal is a notoriously difficult and exhausting effects of withdrawal as well as sickening experience, and learning how to the psychologically stressful tasks of being endure life without drugs has been noted by without family and friends, and trying to researchers, former addicts, and popular remain sober (Daughters et al., 2005). media to be a trying task. Substance-abusing Results demonstrated that it was the individuals low in distress tolerance, participants who were unwilling to finish the therefore, would be more likely than the psychologically stressful tasks who departed individuals with the same issues high in early from the treatment program distress tolerance to postpone entering a (Daughters et al., 2005). This result suggests rehabilitation program, and less likely to that it is not the painful and nauseating complete the same program. physical symptoms of withdrawal, but rather the unpleasant mental state and high mental When this idea was studied, however, stress experienced by recovering addicts that Daughters and colleagues (2005) could not cause an individual to leave a treatment find evidence to suggest a link between program early. intolerance for uncomfortable physical sensations and dropout from long-term The psychopathology behind substance treatment programs. These results are use and dependence, although heavily surprising-a large percentage of individuals researched, has found little conclusive entering a drug rehabilitation program (of all evidence to suggest more effective therapies, types and durations) do not complete particularly in comparison with the efficacy treatment (Crits-Christoph & Siqueland, of the treatments for PTSD and BPD. More

132 MPS I Distress Tolerance & Mental Health Outcomes I Stemke I Pg. 127-136 research into the specific facets of distress substance abuse and dependence has been tolerance and the role it plays in the onset acknowledged by several research studies and treatment of substance abuse and (e.g., Greenfield, Back, Lawson, & Brady, dependence is needed. 2010; Tuchman, 2010) and developing a further understanding of gender differences Directions for Future Research in distress tolerance could lead to improvements in treatment for both men and This review examined both a central women. mechanism in the onset and maintenance of select psychopathologies and treatment Study results (e.g. Howell, Leyro, methods that focused on raising an Hogan, Buckner, & Zvolensky, 2010; individual's distress tolerance to provide Simons & Gaher, 2005) have demonstrated relief from symptoms. Not only were some a significant association between distress of the ways in which distress tolerance tolerance and substance abuse and affected an individual with a dependence, a finding that could potentially psychopathology revealed, but distress be used to improve treatment outcomes of tolerance-oriented treatments were shown to those with substance use issues. If drug be successful in achieving symptom rehabilitation programs were to incorporate reduction. Yet despite increased clinical and a treatment for helping individuals raise research attention to the role of distress their distress tolerance and cope with tolerance in the development and treatment negative mental states and high stress in a of psychopathology, important empirical healthy way in addition to treating physical questions remain. withdrawal symptoms, then ideally, two positive results would emerge. Not only The role of gender is an important area would the individual be clean of the drug for future research. Several studies have they were previously using, but they would suggested that there may be a gender- have learned how to cope with stress in a specific component to distress tolerance healthy way and possibly be less likely to (e.g., Simons & Gaher, 2005; Daughters, return to their previous drug use in the event Reynolds, MacPherson, Kahler, Danielson, of a stressful situation or an unpleasant Zvolensky, & Lejuez, 2009). For example, mental state. in a study of 823 college students, men reported greater distress tolerance than Finally, a potential goal for researchers women (Simons & Gaher, 2005). However, to reach would be to develop the research on a gender component in distress understanding of distress tolerance such that tolerance has been extremely limited, with a it could be applied to identifying individuals gender-specific result often only a who are at risk for developing a mental byproduct, rather than the focus, of the illness. This understanding could be study. Specifically examining gender in supplemented by information such as family relation to distress tolerance could yield history: genetics have been seen to play a interesting results, as well as explain role in the development of disorders like discrepancies in both the onset of certain depression (e.g. Gatt, Nemeroff, Schofield, psychopathologies-such as BPD, which is Paul, Clark, Gordon, & Williams, 2010). generally considered to be more prevalent in Identifying at-risk persons could allow women- and also in the success of treatment. clinicians to provide skills for increasing For instance, a gender component in distress tolerance that could prevent

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symptoms from becoming severe to the completion of this paper would not have point of being debilitating, or perhaps even been possible. partially derail the onset of the disorder completely. Although this goal is not yet within reach, the existing research on PTSD References suggests that it is plausible: Vujanovic and colleagues (2011) had noted in their study APA (American Psychological Association). that low distress tolerance was incrementally (2000). DSM-IV text revision. correlated with increasingly severe PTSD Washington DC: Author. symptoms. Baker, T.B., Piper, M.E., McCarthy, D.E., Conclusions Majeskie, M.R., & Fiore, M.C. (2004). motivation reformulated: A conceptual and empirical focus on An affective processing model of distress tolerance has significantly improved negative reinforcement. Psychological our clinical understanding and outlook of Review, 111, 33-51. doi: 10.1037/0033- PTSD and BPD, with growing attention to 295X.111.1.33 substance use disorders as well. Review of the current research on distress tolerance Comer, R.J. (2008). Fundamentals of suggests that the concept has not only been Abnormal Psychology (Fifth Edition). acknowledged as being significant in the New York: Worth Publishers. onset and maintenance of mental health disorders, but that some promising and Crits-Christoph, P., & Siqueland, L. (1996). effective treatments that include raising an Psychosocial treatment for drug abuse: individual's level of distress tolerance are Selected review and recommendations already in use. Furthermore, the current for national health care. Archives of research revealed a detailed look at the way General Psychiatry, 53, 749-756. doi: in which distress tolerance plays a role in a 10.1001/archpsyc.1996.01830080103015 specific psychopathology. Yet a number of questions remain regarding the application Daughters, S., Lejuez, C., Bornovalova, M., of the study results to improve treatment in Kahler, C., Strong, D., & Brown, R. psychopathologies such as substance use (2005). Distress tolerance as a predictor disorders, the potential association of of early treatment dropout in a distress tolerance with other residential substance abuse treatment psychopathologies than the ones examined facility. Journal Of Abnormal in this literature review, and finally, seeking Psychology, 114(4), 729-734. doi: a way to increase distress tolerance in an 10.1037/0021-843X.114.4.729 individual so that the impact of a mental health disorder in their life is significantly Daughters, S.B., Reynolds, E.K., lowered. MacPherson, L., Kahler, C.W., Danielson, C.K., Zvolensky, M., & Acknowledgement: I would like to Lejuez, C.W. (2009). Distress tolerance acknowledge and to extend my heartfelt and early adolescent externalizing and gratitude towards Dr. Sarah Martin and Dr. internalizing symptoms: The moderating Greg Feldman, without whom the role of gender and ethnicity. Behaviour Research and Therapy, 47(3), 198-205. doi: 10.1016/j.brat.2008.12.001

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