Low Distress Tolerance and Hyperarousal Posttraumatic Stress Disorder Symptoms: A Pathway to Alcohol Use?

Anxiety, distress tolerance, and the relationship between complex posttraumatic stress disorder symptoms and alcohol use in veterans

OBJECTIVES

Little is known about whether distress tolerance and anxiety mediate the relationship between comorbid complex posttraumatic stress disorder (CPTSD) and alcohol use among military veterans. Here, we investigated the contribution of distress tolerance and anxiety on the strength of the CPTSD and alcohol use association. We hypothesized that the impact of a two-factor model of CPTSD derived from subscale scores on the International Trauma Questionnaire (ITQ)-namely ITQ PTSD and ITQ Disturbances in Self Organization (DSO; e.g., issues with affective regulation/self-belief and shame)-on alcohol use severity would be mediated by anxiety but not by distress tolerance.

METHODS

Participants included 403 community-dwelling United Kingdom (UK) veterans (91.64% male, Mage  = 51.15 years, SD = 12.48) recruited as part of a larger, online study.

RESULTS

Findings indicated that the influence of CPTSD symptoms on alcohol use severity was mediated by anxiety, not by distress tolerance, with greater relative impact due to ITQ DSO status than ITQ PTSD status.

CONCLUSIONS

We identified the mediational influence of anxiety and distress tolerance on the association between CPTSD subscales and alcohol use in UK veterans. Interventions for anxiety may be adapted for reducing problematic alcohol use and the impact of CPTSD symptoms in veterans with comorbid PTSD and alcohol use disorder.

Predicting Reasons for Drinking in a Dually-Diagnosed Sample with PTSD and Substance Use Disorders

Objective: Using the negative reinforcement and common factors frameworks, this work assessed whether and how anxiety sensitivity, distress tolerance, and impulsivity relate to reasons for drinking (RFD) in a residential treatment sample with co-occurring alcohol use disorder and posttraumatic stress disorder (AUD-PTSD). Demographic differences were also examined. Method: Participants were 75 (52.0% male, 78.7% white) adults at a residential substance use treatment facility who met criteria for AUD-PTSD with 98.67% meeting criteria for one or more substance use disorders in addition to AUD. Participants completed measures of anxiety sensitivity, distress tolerance, impulsivity, RFD, and AUD-PTSD symptoms. Univariate and multivariate linear regression was used with and without controlling for demographic variables (i.e., age, race, and sex). Results: The positive and negative urgency facets of impulsivity were positively related to both negative affect and cue/craving response RFD with relations maintained after controlling for demographic variables and including PTSD symptom severity (βs .30-.51). There were no significant relations between impulsivity and social RFD. No facets of anxiety sensitivity or distress tolerance were significantly related to RFD domains. Conclusions: Findings suggest that the urgency facets of impulsivity are crucial in understanding negative affect and cue/craving RFD. However, anxiety sensitivity and distress tolerance are not related to RFD in this dually diagnosed AUD-PTSD sample. Treatment considerations and future directions are discussed.

Distress tolerance across substance use, eating, and borderline personality disorders: A meta-analysis

BACKGROUND

Distress tolerance (DT) has received increased attention in recent years due to its purported role in dysregulated behaviours and their clinical manifestations, such as problematic substance use (PSU), disordered eating behaviours (e.g., binge-eating and purging; DEB), and borderline personality disorder (BPD) symptomatology. Despite the proposed transdiagnostic utility of DT across PSU, DEB, and BPD, there has yet to be a systematic and comprehensive examination characterising and comparing its association with this class of impulsive-type psychopathology.

METHODS

A systematic search was conducted across five electronic databases using search terms designed to capture extant literature on the association between DT and PSU, DEB, and BPD symptomatology. A series of meta-analyses were undertaken on correlation coefficients from 81 studies to examine the association between DT and each psychopathology domain, as well as impulsive-type psychopathology overall. Moderator analyses were conducted to examine whether these relationships were moderated by DT measurement type, sample type, age, and gender.

RESULTS

DT shared significant, negative, medium correlations with PSU (r = -.18,), DEB (r = -.20), and BPD symptomatology (r = -.27). The magnitude of these associations was not significantly different across the three psychopathology domains, supporting transdiagnostic conceptualisation. DT measurement type, age, and sample type moderated several of these indicated relationships.

LIMITATIONS

The majority of studies were conducted in adult samples from Western countries, limiting understanding of these relationships across development and different cultures.

CONCLUSIONS

The present findings support the putative transdiagnostic role of DT across PSU, DEB, and BPD, which may ultimately inform novel, cross-cutting interventions.

Childhood abuse, posttraumatic stress symptoms, and alcohol misuse among African-American women

The study explored associations among childhood abuse, post-traumatic stress symptoms (PTSS), and alcohol misuse in a sample of low-income African-American women (N = 172). Using bootstrapping techniques, a mediation effect was found of childhood physical and emotional abuse on alcohol misuse via PTSS symptom severity, avoidance, and hyperarousal, as well as for childhood sexual abuse on alcohol misuse via PTSS symptom severity and hyperarousal. Our results suggest that PTSS indicators, particularly symptom severity and hyperarousal, may be important mechanisms underlying the association of experiences of abuse during childhood and alcohol misuse in adulthood.

Distress tolerance and posttraumatic stress disorder: a systematic review and meta-analysis

The association between distress tolerance (DT) and posttraumatic stress disorder (PTSD) is well established. This study aimed to provide an account of the magnitude of this effect across available studies. From the 2,212 records yielded by the initial search, 56 studies comprised 12,672 participants (M_age = 29.96, SD = 12.05; 44.94% women) were included in the investigation upon a priori criteria. Results demonstrated consistent negative associations between DT and PTSD symptoms, such that lower DT was associated with higher PTSD symptom severity and vice versa; the effect size (ES) was relatively small in magnitude (r = -0.335, 95% CI [-0.379, -0.289]). Moreover, ESs for the DT-PTSD association were significantly greater for studies which examined self-reported DT compared to those that examined behavioral DT. The number of traumatic event types experienced (trauma load) was the most consistent moderator of the DT and PTSD association. The clinical implications of the role of DT in PTSD are discussed.

Examining Transdiagnostic Factors among Firefighters in Relation to Trauma Exposure, Probable PTSD, and Probable Alcohol Use Disorder

Firefighters represent a distinct group of first responders that are at heightened risk of developing posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Assessing the role of transdiagnostic factors that underlie PTSD-AUD associations can inform specialized interventions among this population. This study included urban firefighters (N = 657) with probable PTSD-AUD (n = 27), probable PTSD-alone (n = 35), probable AUD-alone (n = 125), and trauma-exposure-only (n = 470). Methods: All firefighters completed a self-report, online questionnaire battery. Between group differences in anxiety sensitivity (AS), distress tolerance (DT), mindfulness, and emotional regulation difficulties (ERD) were assessed. It was hypothesized that firefighters with probable PTSD-AUD would endorse elevated AS and ERD, and reduced DT and mindfulness in comparison to all other diagnostic groups. Relationship status was included as a covariate in all comparisons. Results: Firefighters with probable PTSD-AUD endorsed elevated AS and ERD, and reduced DT and mindfulness in comparison to firefighters with trauma-exposure-only and probable AUD-alone. Firefighters with probable PTSD-AUD and probable PTSD-alone did not significantly differ. Conclusions: Given these findings, this line of inquiry has great potential to inform specialized, evidence-based mental health programming among firefighter populations, who represent a unique population susceptible to trauma-exposure, PTSD symptomology, and problematic alcohol use.

Distress tolerance and special alcohol metacognitions behave differently in the association of negative affect with alcohol-related patterns in men with problematic alcohol use in the abstinence phase

Negative affect may be related to alcohol-related patterns (e.g., craving and problematic alcohol use). Distress intolerance and positive and negative alcohol-related metacognitions may be underlying mechanisms in this link. This study aimed to evaluate the effect of negative affect including depressive, anxious, and stress symptoms on alcohol craving and problematic alcohol use via the paths of distress tolerance and both positive and negative alcohol-related metacognitions. Three hundred men with problematic alcohol use during the abstinence phase completed psychological and clinical measures. Results showed that craving and negative alcohol metacognitions mediated the relationship between negative affect and problematic alcohol use. Negative affect had a direct and positive effect on craving and indirect effect via distress intolerance and positive alcohol metacognitions. In turn, distress intolerance and positive alcohol metacognitions indirectly and positively affected problematic alcohol use via craving. The study indicates that distress tolerance and distinct alcohol metacognitions may be differently related to various patterns of alcohol-related problems, such that alcohol drinkers with high levels of negative affect, distress intolerance, and positive alcohol metacognitions show higher levels of craving, while high negative affect in relation to high negative alcohol metacognitions and alcohol craving is related to the perpetuation of alcohol use or problematic alcohol use.

Posttraumatic stress, alcohol use, and alcohol use motives among firefighters: The role of distress tolerance

Firefighters represent a unique, vulnerable population at high risk for alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) symptomatology due to the high rates of occupational exposure to traumatic events. To inform specialized alcohol use interventions for firefighters, it is important to understand relevant malleable cognitive-affective factors related to PTSD and AUD symptoms. Distress tolerance (DT), defined as the perceived ability to withstand negative emotional states, is one promising factor relevant to this domain. The current study examined the moderating role of DT in the association of PTSD symptom severity with alcohol use severity and alcohol use motives. Participants included 652 trauma-exposed firefighters (93.3% male; M_age = 38.7 years, SD = 8.6) who endorsed lifetime (ever) alcohol use. Results indicated that there was a significant interactive effect of PTSD symptom severity and DT on coping-oriented alcohol use motives but not other alcohol-related outcomes. These findings were evident after adjusting for alcohol consumption, romantic relationship status, number of years in the fire service, occupational stress, and trauma load. This is the first study to concurrently examine these variables among firefighters and this line of inquiry has great potential to inform intervention efforts for this vulnerable, understudied population.

Theoretical implications and clinical support for heart rate variability biofeedback for substance use disorders

Heart rate variability (HRV) biofeedback is an accessible, cost-effective intervention that has demonstrated clinical value for numerous physical and mental health conditions; however, research on HRV biofeedback in substance use disorders (SUD) is in its nascence. We argue that HRV biofeedback may be particularly beneficial as an adjunct treatment for SUD by targeting bodily systems that are known to be disrupted by chronic substance use and are not historically the focus of psychosocial or pharmacological SUD treatment approaches. In addition to advocating for HRV biofeedback applications in SUD, we identify several gaps within the existing experimental literature, and propose new studies that could accelerate understanding of how and for whom HRV biofeedback is most likely to promote positive behavior change.

Distress tolerance as a mechanism of PTSD symptom change: Evidence for mediation in a treatment-seeking sample

Low distress tolerance, the perceived or actual inability to tolerate negative emotional states, is a transdiagnostic risk marker associated with greater PTSD symptoms and poorer treatment outcomes. However, the role of distress tolerance in PTSD symptom trajectories has not yet been explored. This study examined the mediating role of distress tolerance in PTSD symptom change among outpatients participating in a trial of computerized interventions for anxiety-related and mood-related risk factors. It was hypothesized that pre- to post-intervention change in distress tolerance would predict PTSD symptoms at three- and six-month follow-up, and mediate the effect of condition on PTSD symptoms above and beyond the effects of a competing mediator, anxiety sensitivity. Although condition differences in distress tolerance change were non-significant, distress tolerance change predicted month-three PTSD symptoms and mediated the direct effect of condition on month-three PTSD symptoms. After accounting for the direct effect of condition on month-six PTSD symptoms, distress tolerance change did not predict month-six PTSD symptoms. Findings suggest distress tolerance does play a longitudinal role in PTSD symptom change, and distress tolerance interventions may benefit certain samples who may otherwise not be able to immediately access, or remain in PTSD treatments.

The impact of changes in distress tolerance on PTSD symptom severity post-treatment among veterans in residential trauma treatment

Given that rates of PTSD, particularly among military populations, are increasing, it is critical to gain a better understanding of factors associated with treatment response. Low distress tolerance (DT), conceptualized as the perceived or actual inability to tolerate negative emotional states, may impacts veterans' responses to PTSD treatment. Low DT has been associated with more severe PTSD symptoms in clinical and non-clinical samples; however, its impact on PTSD symptomatology across treatment has yet to be assessed. We examined the impact of changes in DT, from intake to discharge, on post-treatment PTSD symptom severity within two samples of veterans recruited from Veterans Affairs residential PTSD treatment facilities in the northwestern and southern United States (Total N=86; 87% male; 46% White, 39% Black, 9% Latino, 6% Other). Veterans completed the Distress Tolerance Scale and PTSD Checklist (PCL) at intake and discharge from residential PTSD treatment. Regression analyses revealed that, within each veteran sample, those with the greatest improvements in DT had the lowest PCL total and subscale scores at discharge after controlling for respective intake PCL scores. This suggests increases in DT across treatment help explain the degree of benefits experienced by veterans following PTSD treatment.

Changes in posttraumatic stress disorders symptoms during and after therapeutic community drug and alcohol treatment

Purpose

The purpose of this paper is to investigate the changes in posttraumatic stress disorder (PTSD) symptomatology during treatment in a drug and alcohol therapeutic community.

Design/methodology/approach

A repeated measures design was employed that looked at PTSD, depression, anxiety, and stress at a pre- and post-timepoint. A second sample was then evaluated at time of program completion to seven months post-treatment.

Findings

PTSD symptomatology significantly decreased in individuals who had undertaken treatment, and continued to decline post-treatment. This finding was irrespective of any PTSD-specific treatment.

Research limitations/implications

PTSD specific treatment is not necessary to lower the symptomatology. Furthermore, this provides evidence that PTSD and substance use disorders are so highly intertwined that the comorbidity can almost be considered a single, diagnosis.

Originality/value

This is a partial replication of previous research which had not previously been replicated. This research also adds to the limited research which looks at PTSD from the perspective of drug and alcohol rehabilitation.

Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches

BACKGROUND

The co-occurrence of depression and substance use disorders (SUD) is highly prevalent and associated with poor treatment outcomes for both disorders. As compared to individuals suffering from either disorder alone, individuals with both conditions are likely to endure a more severe and chronic clinical course with worse treatment outcomes. Thus, current practice guidelines recommend treating these co-occurring disorders simultaneously.

OBJECTIVES

The overarching aims of this narrative are two-fold: (1) to provide an updated review of the current empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT approaches, including acceptance- and mindfulness-based interventions and behavioral activation (BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression, based upon empirically grounded psychological mechanisms underlying this highly prevalent comorbidity.

RESULTS

Traditional CBT approaches for the treatment of SUD-depression are well-studied. Despite advances in the development and evaluation of various third-wave psychotherapies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression.

CONCLUSION

Informed by this summary of the evidence, we propose a transdiagnostic therapy approach that aims to integrate treatment elements found in empirically supported CBT-based interventions for SUD and depression. By targeting shared cognitive-affective processes underlying SUD-depression, transdiagnostic treatment models have the potential to offer a novel clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychiatric disturbances, such as posttraumatic stress.

The impact of intolerance of emotional distress and uncertainty on veterans with co-occurring PTSD and substance use disorders

The risk of developing a substance use disorder (SUD) is significantly higher among veterans with posttraumatic stress disorder (PTSD). Veterans with this co-occurrence have poorer outcomes than singly diagnosed veterans, which may be related to two risk factors: intolerance uncertainty (IU) and low tolerance of emotional distress (TED). We hypothesized low TED and high IU would independently and interactively relate to heightened PTSD symptomatology and trauma-cue elicited SUD cravings. A sample of 70 veterans (M age=50; 95% men; 65% Black) with co-occurring PTSD-SUD was recruited. The Posttraumatic Stress Disorder Checklist (PCL), Craving Questionnaire, Distress Tolerance Scale, and Intolerance of Uncertainty Scale were administered. In general, low TED and high IU were significantly correlated with the PCL total and subscale scores. When examined within regression models, low TED was associated with elevated PCL scores and trauma-cue elicited SUD cravings; IU was not. However, there was a significant interaction between IU and TED; veterans with elevated IU and low TED had higher PCL Total, Hyperarousal, and Intrusions scores. This highlights the importance of assessing TED and IU among veterans with co-occurring PTSD-SUD, as these risk factors may not only be prognostic indicators of outcomes, but also treatment targets.

Depression, posttraumatic stress, and alcohol misuse in young adult veterans: The transdiagnostic role of distress tolerance

BACKGROUND

Alcohol misuse is common among young adult veterans, and is commonly associated with depression and posttraumatic stress disorder (PTSD). In fact, rates of comorbid depression, PTSD, and problem drinking are high in this population. Although distress tolerance, the capacity to experience and withstand negative psychological states, has been examined as a potential transdiagnostic factor that accounts for the development of mental health disorders, problem drinking, and the comorbidity between these presenting concerns, its role has not been evaluated in a veteran population.

METHODS

Young adult veterans were recruited for an online survey related to alcohol use. Participants (n=783) completed self-report measures of alcohol use, depression and PTSD symptoms, and distress tolerance. Mediation models were conducted to examine whether distress tolerance mediated the relationship between (1) probable PTSD, (2) probable depression, and (3) comorbid probable PTSD and depression with alcohol misuse. Moderated mediation models were conducted to examine gender as a moderator.

RESULTS

Significant bivariate associations were observed among mental health symptoms, distress tolerance, and alcohol misuse. Distress tolerance significantly mediated the relationship between probable depression and PTSD (both alone and in combination) and alcohol misuse. Evidence of moderated mediation was present for probable PTSD and probable comorbid PTSD and depression, such that the indirect effect was stronger among males.

CONCLUSIONS

These results suggest that distress tolerance may be a transdiagnostic factor explaining the comorbidity of depression and PTSD with alcohol misuse in young adult veterans. These findings may inform screening and intervention efforts with this high-risk population.

Distress Tolerance: Associations With Posttraumatic Stress Disorder Symptoms Among Trauma-Exposed, Cocaine-Dependent Adults

The present investigation examined associations between distress tolerance and posttraumatic stress disorder (PTSD) symptoms in a cocaine-dependent sample. Participants were comprised of 138 cocaine-dependent adults (Mage = 45.4, SD = 9.9; 81% male; 76.3% African American) who endorsed trauma exposure, defined according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) PTSD Criterion A. Participants were administered interview-based measures and completed a series of self-report questionnaires. Results indicated that distress tolerance was significantly, incrementally (negatively) associated with PTSD symptom severity, contributing 6.8% of unique variance to the model (p < .001); notably, the overall model explained 44.8% of variance in PTSD symptomatology. Distress tolerance also contributed between 2.7% and 6.8% of unique variance across each of the PTSD symptom clusters (ps < .05). Incremental effects were documented, after accounting for the variance explained by theoretically relevant covariates (i.e., gender, cocaine-use severity, depressive symptoms, trauma-exposure severity). Theoretical and clinical implications are discussed.

PTSD Symptoms, Emotion Dysregulation, and Alcohol-Related Consequences Among College Students With a Trauma History

OBJECTIVE

Posttraumatic stress disorder (PTSD), alcohol use, and alcohol-related consequences have been linked to emotion dysregulation. Sex differences exist in both emotion regulation dimensions and alcohol use patterns. This investigation examined facets of emotion dysregulation as potential mediators of the relationship between PTSD symptoms and alcohol-related consequences and whether differences may exist across sexes.

METHODS

Participants were 240 college students with a trauma history who reported using alcohol within the past three months and completed measures of PTSD symptoms, emotion dysregulation, alcohol consumption, alcohol-related consequences, and negative affect. The six facets of emotion dysregulation were examined as mediators of the relationship between PTSD symptoms and alcohol-related consequences in the full sample and by sex.

RESULTS

There were differences in sexes on several variables, with women reporting higher PTSD scores and lack of emotional awareness. Men reported significantly more drinks per week in a typical week and a heavy week. There were significant associations between the variables for the full sample, with PTSD showing associations with five facets of emotion dysregulation subscales: impulse control difficulties when upset, difficulties engaging in goal-directed behavior, nonacceptance of emotional responses, lack of emotional clarity, and limited access to emotion regulation strategies. Alcohol-related consequences were associated with four aspects of emotion dysregulation: impulse control difficulties when upset, difficulties engaging in goal-directed behavior, nonacceptance of emotional responses, and limited access to emotion regulation strategies. Two aspects of emotion regulation, impulse control difficulties and difficulties engaging in goal directed behavior, mediated the relationship between PTSD symptoms and alcohol-related consequences in the full sample, even after adjusting for the effects of negative affect. When examined separately by gender, impulse control difficulties remained a mediator for men and difficulties engaging in goal directed behavior for women.

CONCLUSIONS

These analyses shed light on processes that may underlie "self-medication" of PTSD symptoms. Gender-specific interventions targeting emotion dysregulation may be effective in reducing alcohol-related consequences in individuals with PTSD. Women may possibly benefit from interventions that focus on difficulties engaging in goal-directed behavior, while men may benefit from interventions that target impulse control difficulties when upset.