by Michael D. Anestis, M.S.
Today's post, admittedly, might be more interesting to a nerd such as myself, whose work is primarily focused on this particular issue, than it will be to a broader audience, but I was excited by this paper and wanted to talk about it a bit today. A host of researchers - Kate McHugh, Stacey Daughters, Carl Lejuez, Heather Murray, Bridget Hearon, Stephanie Gorka, and Michael Otto (in press) - conducted a study soon to be published in Cognitive Therapy and Research in which they compared many of the different ways in which we measure distress tolerance.
You might remember from earlier articles on this topic that distress tolerance is a measure of the ability to tolerate distressing states and/or the ability to maintain goal-directed behavior while experiencing distress (Zvolensky & Otto, 2007). Across studies, researchers have used a number of self-report questionnaires as well as a variety of behavioral measures of distress tolerance, with both forms of measurement painting a similar picture: the less able an individual is the tolerate negative emotions, the more likely he or she is to engage in a number of problematic behaviors. These behaviors include smoking (Quinn et al., 1996), binge eating and purging (Anestis et al., 2007), substance use relapse (e.g., Daughters et al., 2005), and non-suicidal self-injury (Nock & Mendes, 2008). These results clearly demonstrate that low levels of distress tolerance are problematic, but some important questions remain.
First of all, despite the rather clear broad picture painted by the data described above, ambiguity remains regarding whether self-report and behavioral measures of distress tolerance are actually measuring the same thing. Secondly, although the idea of distress tolerance is a coherent and meaningful one, it remains possible that individuals have the ability to tolerate different levels of different types of distressing experiences (e.g., physical discomfort, anxiety, frustration, anger) and that those differences are meaningful. McHugh and her colleagues (in press) sought to address these issues through a series of studies conducted across four independent samples. Sample one included undergraduates and community volunteers in the Boston area (n = 71), sample two included individuals entering a residential drug treatment center in the Washington DC area (n = 129), sample three included smokers recruited from the community in the Boston area (n = 54), and sample four included early lapsing nicotine dependent, non-treatment seeking adults (n = 44) from the Boston area community.
Across these four samples, the authors administered a wide variety of measures of distress tolerance. In each sample, participants filled out at least one self-report measure of distress tolerance and took part in at least one behavioral measure of distress tolerance. Some of these measures were directly relevant to the distress tolerance concept and others were more tangentially related (e.g., anxiety sensitivity). To see the full list and description of each of these measures, I encourage you to read the original article.
What the authors found is extremely important to those of us who research distress tolerance and focus on it as an important topic in treatment. First of all, self-report measures of distress tolerance tend to correlate fairly highly with one another, which means that while they may touch upon slightly different topics or components of the same topic, overall they are highly related. Similarly, behavioral measures of distress tolerance tend to correlate quite strongly with one another. Self-report measures and behavioral measures, on the other hand, do not tend to correlate with one another. Having conducted multiple studies that have found this same outcome, it was actually quite comforting to me to see this from a group of folks who are at the forefront of this area! So, what does this mean? Although self-report and behavioral measures of distress tolerance tend to predict many of the same behavioral outcomes, it appears that they are actually measuring concepts that are different enough from one another that it might be unwise to refer to them both as measures of "distress tolerance." An initial response might be to say that we should then simply stick with behavioral measures, as they offer a number of conceptual advantages; however, legitimate questions can be asked regarding whether the distress induced by these tasks is truly similar to the types of distress experienced as intolerable outside of laboratories. Additionally, because the inability to tolerate distress does not necessarily indicate a tendency to quit frustrating tasks, it remains possible that the insight provided from self-report measures actually touches upon important components of distress tolerance not measured by the current behavioral approaches. In other words, there is no simple, clear cut answer here.
All this being said, there were a couple of exceptions to the rule. Specifically, a self-report measure of anxiety sensitivity, which involves the fear of anxiety-related sensations (particularly physical sensations) was significantly correlated with behavioral measures of physical distress tolerance (e.g., ability to keep arm in extremely cold water) but not emotional distress tolerance (e.g., the ability to maintain goal directed behavior while frustrated). Additionally, behavioral measures of physical distress tolerance were not generally correlated with behavioral measures of emotional distress tolerance. These series of findings are supportive of an important possibility: that distress tolerance is too broad of a term and that individuals maintain different tolerance levels for different forms of distress. Think of it this way, the idea of negative emotions is a useful one with a strong history of informative research; however, it is meaningful to know whether an individual is experiencing anger, frustration, fear, sadness, or another negative emotion rather than simply knowing that they are upset. The same idea applies here. Knowing whether or not an individual can tolerate distress in general is useful and we have certainly gained a lot from research that has considered the idea in this manner; however, we might become better at predicting specific outcomes if we shift gears and focus instead on the ability of individuals to tolerate specific forms of distress.
In the next year, I hope to follow the lead of McHugh et al (in press) by using some of the data I have collected over the past several years to test these and other hypotheses using slightly different assessment measures. In the meantime, I look forward to seeing where they go next with these ideas. Additionally, I look forward to the release of the upcoming book - Distress Tolerance - edited by Michael Zvolensky, Amit Bernstein, and Anka Vujanovic and published by Guilford Press (featuring a chapter by myself and several FSU colleagues on distress tolerance in eating disorders), as these ideas will no doubt be expanded upon in that text.
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Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident and the University of Mississippi Medical Center.
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