What does Distress Tolerance have to do with Depression? A Review

Distress tolerance is often conceptualized as one’s ability to tolerate and withstand negative or uncomfortable emotional states. Distress tolerance was initially studied primarily in relation to risky or dangerous behaviors like smoking and nonsuicidal self-injury. However, with continued research, distress tolerance has emerged as a transdiagnostic risk factor for psychopathology (Leyro et al. 2010) and is being increasingly recognized for its role in anxiety, obsessions, and other internalizing symptoms (e.g., Cougle et al., 2011).

Surprisingly, distress tolerance has received limited attention in the depression literature, despite negative affect being a hallmark symptom of depression. Though there is a good rationale for moving more toward transdiagnostic research and focusing less on any one specific disorder, the depression literature has unique and important theories and hypotheses that have yet to be incorporated into our understanding of distress tolerance and its relationship to psychopathology.

To address this gap in the literature, we have reviewed and integrated findings from different literatures to explore the relationship between distress tolerance and symptoms of depression, and hopefully provide a basis for additional work in this area.

We found that studies using self-reported distress tolerance nearly unanimously show that low self-reported distress tolerance is associated with higher symptoms of depression. However, when distress tolerance is measured through behavioral tasks, the results are mixed. Some studies have found that depressed samples quit distressing tasks more quickly than healthy controls; however, when depressive symptoms are measured continuously (rather than looking at depressed vs. nondepressed groups), most studies did not show a relationship between distress tolerance and depressive symptoms.

Longitudinal studies also show mixed results. Of the three longitudinal studies, one did not show that distress tolerance predicted symptoms of depression over time, and two studies did find that distress tolerance predicted symptoms of depression over time. It may be worth noting that the study that did not find that distress tolerance predicted symptoms of depression over time used a behavioral task as a measure of distress tolerance, and the two studies that did find a relationship used self-report measures of distress tolerance.

Many clinicians learn about distress tolerance because of its integration into treatments such as dialectical behavior therapy. This may lead one to wonder what happens to distress tolerance and depressive symptoms throughout treatment. Two studies have found that distress tolerance improves throughout treatment and is associated with improvements in depressive symptoms. Additionally, a study by Bornovalova and colleagues (2012) found that a treatment focused on increasing distress tolerance skills resulted in decreased symptoms of depression.

Evidence strongly suggests that distress tolerance is associated with symptoms of depression such that individuals with low distress tolerance report more depressive symptoms. The next question is why and how this relationship may come to exist. Both cross-sectional and longitudinal studies suggest that distress tolerance impacts the ways in which one copes with stressful events, which is predictive of depressive symptoms. Individuals who have difficulty tolerating distress may engage in maladaptive forms of coping that reduce distress quickly in the moment, but ultimately become problematic over time.

The lack of research integrating depression-specific theories may be an important oversight in the distress tolerance literature. Reward devaluation theory (Winer & Salem, 2016) posits that for some individuals, prospective happiness and positivity has been so consistently paired with negative outcomes that it loses its rewarding quality, and over time, may ultimately become distressing.

The distress tolerance literature focuses on one’s ability to tolerate negative emotional states; however, for some individuals, this definition may need to be expanded to account for the fact that, to some, positivity may be distressing. If this is the case, it would be important to address positivity-induced distress when treating symptoms of depression. Many popular treatments for depression involve engaging in activities meant to increase positive affect (e.g., behavioral activation). If some individuals are distressed by positivity, they may have ambivalence about engaging in these types of treatment. Because there is no current work in this area, there are no evidence-based guidelines on how to treat individuals who may be distressed by positivity.

In summary, our review has found a strong negative relationship between distress tolerance and symptoms of depression; however, the limited theory-driven work in this area impedes one’s ability to draw strong conclusions about the exact nature of this relationship. Future work in this area—especially regarding distress tolerance in individuals who devalue reward—could provide important information about distress tolerance and its impact on psychopathology.

Discussion Questions

  1. The distress tolerance literature has often studied populations that tend to engage in risky and/or dangerous behaviors. How might having low distress tolerance look different in individuals who are depressed?
  2. If some individuals are distressed by positivity, how might that alter our conceptualization of distress tolerance?

About the Author

Alisson N. S. Lass is a graduate student at Mississippi State University, where she works with Dr. E. Samuel Winer. Alisson received her M.S. in Psychology from North Dakota State University, where she worked with Dr. Paul Rokke. Her research focuses on cognitive and affective factors that precede and maintain symptoms of depression.

Reference Article

Lass, A. N., & Winer, E. S. (2020). Distress tolerance and symptoms of depression: A review and integration of literatures. Clinical Psychology: Science and Practice, e12336.

References

Bornovalova, M. A., Gratz, K. L., Daughters, S. B., Hunt, E. D., & Lejuez, C. W. (2012). Initial RCT of a distress tolerance treatment for individuals with substance use disorders. Drug and Alcohol Dependence, 122(1-2), 70-76. https://doi:10.1016/j.drugalcdep.2011.09.012

Cougle, J. R., Timpano, K. R., Fitch, K. E., & Hawkins, K. A. (2011). Distress tolerance and obsessions: an integrative analysis. Depression and Anxiety, 28(10), 906-914. https://doi:10.1002/da.20846

Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychological Bulletin, 136(4), 576-600. https://doi:10.1037/a0019712

Winer, E. S., & Salem, T. (2016). Reward devaluation: Dot-probe meta-analytic evidence of avoidance of positive information in depressed persons. Psychological Bulletin, 142(1), 18-78. https://doi:10.1037/bul0000022


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