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

Introjected regulation and academic burnout: A moderated mediation model of social comparison and distress overtolerance

The primary purpose of this study is to examine the mediation effect of Contrastive Upward Comparison (CUC) on the relationship between introjected regulation and exhaustion (i.e., introjected regulation-CUC-exhaustion). It is also aimed to examine the moderation effect of distress overtolerance on this mediated relationship. In order to resolve the uncertainty about the causality of cross-sectional studies, this study worked on the relationship among the variables by setting an alternative model (i.e., CUC-introjected regulation - exhaustion). The participants were 167 (females, 70.7%) undergraduate and graduate students in South Korea. The results of this study indicated that introjected regulation showed indirect and significant effect on exhaustion via CUC. However, in the alternative model, the indirect effect of introjected regulation in the relationship between CUC and exhaustion was not significant. Furthermore, high distress overtolerance buffered the relationship between introjected regulation and CUC, while it strengthened the association of CUC and exhaustion. Lastly, the results of moderated mediation suggested that students with higher distress overtolerance, experienced more CUC, and emotional exhaustion. The implications and limitations were also discussed.

A Narrative Commentary on the Use of a Rational Emotive Behavior Therapy-Informed Group to Address Irrational Beliefs, Posttraumatic Stress Disorder, and Comorbidities

Irrational beliefs of Demandingness, Catastrophizing, Low Frustration Tolerance, and Depreciation have demonstrated prevalence in disparate areas of life, including psychopathology, the military, politics, religion, and education. Individuals with mental health concerns, such as Post-Traumatic Stress Disorder (PTSD), endorse elevations in such thoughts compared to the general population. This commentary describes the rationale for focusing on irrational beliefs in efforts to address PTSD and presents the Rational Emotive Behavior Therapy (REBT)-Informed Group for PTSD as a potential novel application of a well-established intervention. In support of these suggestions, we present a narrative review of the published work on irrational beliefs and REBT tenets as relevant for PTSD. We then introduce and describe the REBT-Informed Group intervention, summarize the prior preliminary research conducted by our group, and present some novel data from a re-analysis of this prior work. We end with commentary related to future directions of REBT approaches for PTSD to address limitations and expand the impact of the treatment to military and other Veteran or civilian populations.

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.

Distress tolerance mitigates effects of posttraumatic stress, traumatic brain injury, and blast exposure on psychiatric and health outcomes

BACKGROUND

Exposure to blasts is common among service members and history of these exposures has been associated with chronic psychiatric and health outcomes. Evidence suggests that distress tolerance (DT) may moderate this relationship and be a valuable treatment target in this population. The purpose of this manuscript was to evaluate DT as a modifying factor in the association between posttraumatic stress disorder (PTSD), mild traumatic brain injury (TBI), blast exposure, and functional indicators.

METHOD

Participants were 275 (86.55% male) combat veterans who served in Iraq or Afghanistan after September 11, 2001. Clinical interviews for PTSD diagnosis, TBI history, and blast exposure were administered, and participants completed self-report questionnaires (DT, PTSD symptom severity, depressive symptom severity, neurobehavioral symptom severity, sleep quality, pain interference, and quality of life).

RESULTS

DT was significantly associated with all functional indicators beyond PTSD diagnosis, mild TBI, and blast severity. There were significant interaction effects between DT and PTSD diagnosis for posttraumatic stress symptom severity, sleep quality, and quality of life. Specifically, there were significant differences in these reported functional indicators between individuals with and without a PTSD diagnosis as DT increases, such that reported symptoms were lower (quality of life better) for individuals without PTSD as DT improved.

CONCLUSION

Our results demonstrate that DT might be a key factor in postdeployment function for military service members. Treatments targeting DT may be particularly effective in individuals who attribute psychiatric symptoms to history of blast exposure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The main and interactive effects of distress tolerance and reward function on posttraumatic stress disorder symptoms among firefighters

BACKGROUND

Firefighters are at heightened risk of posttraumatic stress disorder (PTSD), underscoring the importance of understanding clinically targetable factors to inform evidence-based intervention development. Hedonic capacity, or the ability to experience pleasure, is a facet of reward functioning. Anhedonia (i.e., low or absent hedonic capacity) is a hallmark symptom of PTSD. Distress tolerance (DT), or the perceived ability to withstand negative emotional states, has also demonstrated associations with PTSD.

OBJECTIVE

The purpose of the present study was to examine the main and interactive effects of self-reported hedonic capacity (Snaith-Hamilton Pleasure Scale) and DT (Distress Tolerance Scale) on PTSD symptom severity among firefighters.

METHOD

A hierarchical linear regression was performed among a sample of 802 trauma-exposed career firefighters, who completed a battery of self-report questionnaires. Covariates included trauma load (i.e., number of trauma types), years in the fire service, and depression symptoms (excluding anhedonia).

RESULTS

Both hedonic capacity (B = 2.71, SE = .95, p = .005) and DT (B = -.21, SE = .03, p < .001) were incrementally associated with PTSD symptom severity. The interactive effect of hedonic capacity and DT was associated with heightened PTSD symptom severity (B = .25, SE = .07, p < .001).

CONCLUSIONS

Hedonic capacity and DT were independently and transactionally associated with heightened PTSD symptom severity among trauma-exposed firefighters. These findings provide evidence for the utility in developing interventions that target DT and impaired hedonic capacity among firefighters, particularly those experiencing PTSD symptomatology. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Distress intolerance and pain catastrophizing as mediating variables in PTSD and chronic noncancer pain comorbidity

OBJECTIVES

Several studies have demonstrated posttraumatic stress disorder (PTSD) and chronic pain comorbidity. However, there is a lack of research on the psychological variables that might explain their co-occurrence. We investigated the mediating role of distress intolerance and pain catastrophizing in this relationship.

METHODS

A moderated mediation model was tested. The sample comprised 114 individuals with chronic noncancer pain (90 women and 24 men; mean age, of 60.04 years [SD=9.76]).

RESULTS

Catastrophizing had a significant effect on PTSD. Distress intolerance mediated catastrophizing and PTSD, and pain intensity moderated this relationship.

CONCLUSIONS

New insights are provided into the psychological variables that may explain PTSD and chronic noncancer pain comorbidity.

Distress Tolerance and Emotion Regulation as Potential Mediators Between Secondary Traumatic Stress and Maladaptive Coping

The extant literature has illustrated that protective service workers experience negative repercussions associated with their job (including the development of secondary traumatic stress; STS) and may utilize maladaptive coping mechanisms. Developing an improved understanding of factors that might explain the relationship between STS and the utilization of maladaptive coping mechanisms is warranted. This study sought to examine emotion regulation and distress tolerance as potential mediators between STS and the utilization of maladaptive coping mechanisms. Participants were 152 elder protective service workers and 105 child protective service workers who completed an online survey of self-report measures of emotion regulation, distress tolerance, STS, and coping behaviors. A parallel multiple mediator model was analyzed using structural equation modeling (SEM) to examine the hypothesis that distress tolerance and emotion regulation would mediate the relationship between STS and the utilization of maladaptive coping. Our hypothesis was partially supported as the effect of STS on maladaptive coping was mediated by emotion regulation but not by distress tolerance. The results from this study have both prevention and intervention implications. From a prevention perspective, efforts could be directed at teaching emotion regulation skills to those at risk for developing STS as a mechanism for decreasing the probability of denial, substance use, behavioral disengagement, and self-blame that may occur as a consequence of STS. From an intervention perspective, some of the negative sequelae of exposure to STS may be averted by teaching EPS and CPS workers who present with STS symptoms, emotion regulation skills.

Posttraumatic stress and substance use among military veterans: Associations with distress intolerance and anxiety sensitivity

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is highly prevalent among military veterans and represents a difficult-to-treat comorbidity. Distress intolerance (DI; i.e., the perceived inability to tolerate negative emotional states) and anxiety sensitivity (AS, i.e., the fear of anxiety-related sensations) are two promising targetable mechanisms with potential to predict and improve treatment outcomes for veterans with PTSD/SUD. We hypothesized that PTSD symptom severity would be related to (a) alcohol use severity and (b) drug use severity through DI and AS, evaluated concurrently. Participants included 120 military veterans (98.3% male; M_age = 41.41, SD = 10.77) presenting for psychological services at a Veterans Affairs PTSD/SUD clinic. Results indicated that PTSD symptom severity was related to alcohol use severity through AS, but not DI; and PTSD symptom severity was related to drug use severity through DI, but not AS. Clinical and research implications are discussed.

Distress tolerance: prospective associations with cognitive-behavioral therapy outcomes in adults with posttraumatic stress and substance use disorders

74Distress tolerance (DT; perceived or actual ability to tolerate aversive physical or emotional states) is related to both posttraumatic stress disorder (PTSD) symptoms and substance use disorders (SUD). This investigation evaluates self-report and behavioral measures of DT as potential predictors of PTSD and SUD cognitive-behavioral therapy outcomes. Participants included 41 treatment-seeking adults (53.7% women; 73.2% African American; M_age = 44.90, SD = 9.68) who met at least four symptoms of DSM-5 PTSD and DSM-IV substance dependence, assessed via structured interviews. At baseline (pre-treatment), participants completed the Distress Tolerance Scale (DTS), Mirror-Tracing Persistence Task (MTPT), Breath Holding task, and Paced Auditory Serial Addition Task. The Clinician-Administered PTSD Scale for DSM-5 severity scores and percent days of primary substance use, measured via Timeline Follow-back, were used as indicators of PTSD symptoms and substance use, respectively. Covariates included treatment condition, baseline PTSD symptom severity, and baseline substance use. Lower perceived DT at baseline (DTS total score) was associated with higher PTSD symptom severity at end-of-treatment. Lower behavioral DT at baseline (MTPT duration) was associated with higher substance use at the conclusion of treatment (i.e. proportion of number of use days to total number of days between two final treatment sessions).

The predictive role of hair cortisol concentrations for treatment outcome in PTSD inpatients

Psychological treatments of posttraumatic stress disorder (PTSD) are associated with non-response rates of up to 50%. This fact highlights the need to identify characteristics of poorer treatment outcome. Among others, previous evidence focused on the role of dysfunctional cortisol secretion which has been related to the development, maintenance and treatment of PTSD. Particularly, promising evidence stems from research using hair cortisol analysis which allows for a reliable assessment of cortisol secretion over several months. Another variable that has been linked to both HCC and non-response to treatment is childhood maltreatment (CM). In order to examine the predictive value of pre-treatment hair cortisol concentrations (HCC), treatment-related changes in HCC as well as CM for changes in PTSD symptomatology, we set up a prospective study in which we followed 52 female PTSD patients over the course of a trauma-focused inpatient treatment. Specifically, 3-month integrated HCC were assessed at treatment entry, at discharge and on average five months later accompanied by assessments of PTSD, overall and depressive symptomatology. CM was measured at treatment entry. Self-report indices improved following inpatient treatment. No evidence for pre-treatment HCC to be associated with changes in PTSD symptoms was revealed. However, attenuated pre-treatment HCC predicted less improvement in overall symptomatology from treatment entry to discharge. This effect lost significance after adjusting for baseline dissociative symptoms. Neither changes in HCC nor CM were predictive of treatment response. Pre-treatment cross-sectional analyses revealed no association between HCC and CM. The current hair cortisol data provided little evidence for a predictive role of lower long-term integrated cortisol secretion for poorer inpatient treatment outcome. If corroborated by further research in larger PTSD samples with much more methodological rigor, these data might be a valuable basis for future tailored research projects.

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.

"Oh, My God! My Season Is Over!" COVID-19 and Regulation of the Psychological Response in Spanish High-Performance Athletes

Background: In an unprecedented situation of interruption of the sporting dynamics, the world of sport is going through a series of adaptations necessary to continue functioning despite coronavirus disease 2019 (COVID-19). More than ever, athletes are facing a different challenge, a source of discomfort and uncertainty, and one that absolutely alters not only sports calendars, but also trajectories, progressions, and approaches to sports life. Therefore, it is necessary to identify the levels of psychological vulnerability that may have been generated in the athletes, because of the coexistence with dysfunctional responses during the COVID-19 experience, and which directly influence the decrease of their mental health. Methods: With a descriptive and transversal design, the study aims to identify the state of the dysfunctional psychological response of a sample of Spanish athletes (N = 284). The DASS-21 (Depression, Anxiety, and Stress Scale), Toronto-20 (alexithymia), and Distress Tolerance Scale questionnaires were administered to a sample of high-level Spanish athletes in Olympic programs. Results: The results suggest that the analyzed athletes indicate high levels of dysfunctional response (e.g., anxiety, stress, depression, and alexithymia) when their tolerance is low. In addition, the variables show less relational strength, when the capacity of tolerance to distress is worse and age is lower. At the same time, the greater the anxiety and uncertainty are, leading to more catastrophic and negative thoughts, the younger the athletes are. Conclusions: It is clear that both age and tolerance to distress are considered adequate protective factors for psychological vulnerability in general and for associated dysfunctional responses in particular. Moreover, the psychological resources offered by more experienced athletes are also a guarantee of protection against negativity and catastrophism.

Distress intolerance mediates attentional control on posttraumatic stress symptoms: Evidence from two clinical samples

Theoretical models emphasize the importance of both affective and cognitive risk factors in the development of posttraumatic stress symptoms (PTSS). Two such factors predicting PTSS have been studied extensively: distress intolerance (DI) - an affective factor indicative of the ability to tolerate negative affective states - and attentional control (AC), a cognitive factor reflecting the ability to flexibly shift and maintain attention to goal-relevant tasks. Previous work primarily highlights the independent contributions of DI and AC and their interaction to predict PTSS. Some models, however, suggest a mediational pathway such that AC indirectly affects PTSS via diminished DI. The current paper addressed this gap by first attempting to replicate prior findings, while also exploring this mediation model. Results were examined in two clinical samples - a trauma-exposed sample of adults (study 1; N = 73) and trauma-exposed treatment-seeking adults (study 2; N = 204). Results partially supported our hypotheses; both studies failed to replicate prior moderation findings, but our mediational hypothesis was supported in both samples. Low AC appears to decrease an individual's tolerance for distressing situations, which in turn increases the severity of PTSS. Results suggest that PTSD treatments may benefit by incorporating components of AC, DI, or a combination of the two to mitigate PTSS. Taken together, this study provides a novel examination of how cognitive and affective risk factors, namely AC and DI, work in tandem to increase PTSS.

Distress Tolerance as a Familial Vulnerability for Distress-Misery Disorders

Low perceived distress tolerance (DT), a trait-like individual difference factor reflecting one's perceived ability to withstand aversive affective states, has been linked with current internalizing and substance use disorders (SUDs). However, perceived DT has not been systematically evaluated as a familial, transdiagnostic vulnerability factor for internalizing and SUDs. The current study tested whether perceived DT runs in families and whether it is reduced among individuals with versus without remitted internalizing/SUD psychopathology. Perceived DT and internalizing/SUDs were measured in 638 individuals (nested within 256 families). Analyses also adjusted for the effects of neuroticism to test whether DT was a specific vulnerability factor independent of temperamental negative affect. Analyses revealed that perceived DT was lower in individuals with remitted distress (i.e., major depression, generalized anxiety disorder, posttraumatic stress disorder) but not fear disorders (i.e., panic disorder, social anxiety disorder, specific phobia, obsessive-compulsive spectrum disorders) relative to healthy controls, and the effect of distress-misery disorder history remained significant when adjusting for neuroticism. Perceived DT was not significantly different among individuals with versus without a remitted SUD. There were no effects for comorbid SUD and distress-misery disorders. Finally, perceived DT was also significantly correlated within families, suggesting that it runs in families. Overall, results suggest that independent of neuroticism, low perceived DT is a familial vulnerability for distress (but not fear or substance use) disorders.

Distress Intolerance and Smoking Topography in the Context of a Biological Challenge

INTRODUCTION

Distress intolerance (DI), one's perceived or behavioral incapacity to withstand distress, is implicated in psychopathology and smoking. This study evaluated the effect of DI on smoking reinforcement in the context of a carbon dioxide (CO2) biological challenge.

METHODS

Adult daily smokers (n = 90; 48.9% female) were randomized to receive a single inhalation/breath of 35% CO2-enriched air (n = 45) or compressed room air (n = 45). Perceived DI was assessed before the challenge. Smoking reinforcement was examined via average post-challenge puff volume across puffs and at the puff-to-puff level.

RESULTS

Higher DI was associated with an increased average puff volume (b = -4.7, p = .031). CO2 produced decreased average puff volume compared with room air (b = -7.7, p = .018). There was a DI* condition interaction (ƒ2 = 0.02), such that CO2 decreased average puff volume compared with room air in smokers with higher DI (b = -13.9, t = -3.06, p = .003), but not lower DI. At the puff-to-puff level, there was a significant interaction between DI, condition, and cubic time (b = 0.0003, p =. 037). Specifically, room air produced large initial puff volumes that decreased from puff to puff over the cigarette for high- and low-DI smokers. CO2 produced persistent flat volumes from puff to puff over the cigarette for higher DI smokers, whereas CO2 produced puff volumes like that of room air in lower DI smokers.

DISCUSSION

Findings suggest DI heightens smoking reinforcement generally, and in the context of intense cardiorespiratory distress, is associated with stable and persistent smoking. DI is a promising therapeutic target that, if addressed through psychological intervention, may improve cessation outcomes by decreasing smoking reinforcement.

IMPLICATIONS

This study contributes to our understanding of the relationship between DI and smoking reinforcement, via examining these processes in response to acute cardiorespiratory distress. Specifically, we found that smokers who are less tolerant of distress, as opposed to those who are more tolerant, evince a decrease in average puff volume, and consistently low puff-to-puff volume, in response to a biological stressor. These findings suggest that smokers high in DI alter smoking behavior following acute cardiorespiratory distress, perhaps to reduce overstimulation, yet also persist in smoking in a manner that suggests an inability to achieve satiation.

Affective dynamics among veterans: Associations with distress tolerance and posttraumatic stress symptoms

We tested a dynamic structural equation model (DSEM; Asparouhov, Hamaker, & Muthén, 2018) of positive and negative affect in 254 veterans with approximately 1.5 years of experience sampling data. The analysis provided estimates of several aspects of veteran's emotional experience including "trait" positive and negative affect (i.e., mean levels), inertia (i.e., tendency for emotions to self-perpetuate), innovation variance (conceptualized as lability, reactivity, or exposure to stressors), and cross-lagged associations between positive and negative affect. Veterans with higher trait negative affect had more negative affect inertia and innovation variance. This suggests a pattern whereby the veteran has more negative reactions, and negative emotions, in turn, tend to maintain themselves, contributing to higher trait negative affect. In contrast, veterans with higher trait positive affect exhibited more positive affect innovation variance (e.g., positive reactivity). Although veterans showed some consistency in dynamics across emotions (e.g., positive and negative reactivity were positively correlated), trait positive and negative affect were not significantly associated. Veterans with higher posttraumatic stress symptoms (PTSS) at baseline exhibited higher reactivity to negative events, less positive affect, and more negative affect during the follow-up. Veterans with higher distress tolerance reported not only lower PTSS but also a more adaptive pattern of affective experience characterized by lower inertia and reactivity in negative affect and more positive lagged associations between negative affect and subsequent positive affect. The results demonstrated that distress tolerance and PTSS in veterans were associated with dynamics of positive and negative emotion over time, suggesting specific differences in affect regulation processes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The effects of exercise on transdiagnostic treatment targets: A meta-analytic review

BACKGROUND

The present study meta-analytically reviewed the effects of exercise on four transdiagnostic treatment targets: anxiety sensitivity (AS), distress tolerance (DT), stress reactivity (SR), and general self-efficacy (GSE).

METHODS

We conducted systematic searches of peer-reviewed studies in bibliographical databases (Cochrane Library, psychINFO, PubMed) before April 1, 2018. Only randomized controlled trials (RCT) evaluating the effect of exercise on AS, DT, SR, or GSE using at least one validated outcome instrument in a sample of adolescents (≥13 years old) or adults were selected. We employed a meta-analysis of effects using random-effects pooling modeling for each treatment target.

RESULTS

The systematic search yielded 28 RCTs meeting eligibility criteria. Exercise interventions had a large effect on reducing AS (six studies, Hedges's g = 0.72, p = .001), a medium effect on increasing GSE (eight studies, Hedges's g = 0.59, p < .001), and a small effect on reducing SR (ten studies, Hedges's g = 0.32, p < .001). Evidence from four studies suggested that exercise interventions had a small but non-significant effect on increasing DT (Hedges's g = 0.21, p = .26).

CONCLUSIONS

This meta-analysis provides preliminary evidence exercise can engage certain transdiagnostic targets. Further research is required to optimize exercise intervention parameters to achieve the strongest effects on these important mechanistic variables.