Distress intolerance in substance dependent patients

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ScienceDirect Comprehensive Psychiatry 55 (2014) 960 – 965 www.elsevier.com/locate/comppsych

Distress intolerance in substance dependent patients Kadir Özdel a,⁎, Suat Ekinci b b

a Department of Psychiatry, Diskapi YB Teaching and Research Hospital, Ankara, Turkey Department of Psychiatry, Addiction Services, Balikli Rum Foundation Hospital, Istanbul, Turkey

Abstract This study seeks to extend the literature by examining distress tolerance (DT) levels for a substance dependent group of individuals. Next, it considers the potential relationship of DT levels with substance dependence features and finally, it compares those factors with a healthy control group. This study included 93 individuals (49 substance dependent and 44 healthy controls). Participants were evaluated using the Structured Clinical Interview for DSM-IV Axis I Diagnosis (SCID-I) and given the Distress Tolerance Scale (DTS), Beck Depression Inventory (BDI), and State & Trait Anxiety Inventory (STAI). Consistent with our expectations, the substance dependent group showed higher scores on the BDI and STAI, and lower scores on the DTS. There was no difference between the single drug dependent group and multiple substance-dependent groups, and their DT levels were not correlated with the duration of substance use, nor with the age of first substance use. Instead, DT was strongly correlated with trait anxiety, state anxiety, and depressive symptoms. The DT levels of this group of substance dependent individuals were very low in comparison to controls and to other groups reported in the literature. Our results suggest that distress tolerance may represent a therapeutic target factor in substance dependency treatment. Limitations and future research directions are also discussed. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Distress tolerance (DT) is a well established psychological construct that is defined as an individual’s perceived capacity to withstand negative emotional states [1,2]. Although this construct shares some qualities with frustration or discomfort tolerance, it is a unique concept related to tolerance for negative psychological distress [1,3]. The early literature on distress tolerance dates back to the 1980’s. As described in Linehan’s work, DT was originally considered most relevant to borderline personality disorder [4]. Marsha Linehan has highlighted the importance of DT as a factor in the treatment of challenging psychological problems in her dialectical behavioral therapy (DBT) [5]. According to DBT, a promising therapy modality for borderline personality disorder (BPD), an individual’s low distress tolerance is one of the main contributors to disruptive behaviors. At the same time, one of the main purposes of DBT treatment is to boost the distress tolerance ⁎ Corresponding author at: Diskapi Yildirim Beyazit Egitim ve Arastirma Hastanesi, Psikiyatri Klinigi, 06010 Altindag/Ankara, Turkey. Tel.: +90 3125962000; fax: +90 312318 66 90. E-mail address: [email protected] (K. Özdel). 0010-440X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.12.012

level of a patient [6]. In the last decade, primarily as related to an individual’s capacity to withstand emotional distress, DT has been a focus of research in the area of substance use [2,7,8] and other psychological disorders such as major depressive disorder, eating disorders and anxiety disorders [9–13]. Previous research has primarily been conducted in normal populations in addition to a few disordered populations. This research suggests that distress tolerance has a relationship with depression and anxiety symptoms, and also shows an independent association with the symptom measurements of various anxiety disorders [13–15]. In addition to anxiety disorders, Ellis et al. [12] found that decreased distress tolerance, along with increased anger and blunted physiological arousal, distinguished depressed and non-depressed individuals. DT has been found, either directly or indirectly, to be related to suicidal behavior, smoking relapse, risky sexual behavior and eating disorders [11,16–18]. In addition, some have suggested that DT may be specifically related to the motives for alcohol use [19] and cannabis abuse [20]. Although there are some theoretical studies in this area, to the best of our knowledge, there has been no study with a control group conducted on a substance dependent group of individuals.

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Therefore the purpose of this study is twofold: first, to compare distress tolerance levels and factors as well as anxiety and depressive symptom levels between a substance dependent group and non-substance abusing healthy controls and second, to investigate whether there is a relationship between substance use features and distress tolerance levels.

2. Methods 2.1. Participants The study sample was composed of 93 individuals (49 residential patients with substance dependence diagnoses and 44 psychologically healthy controls). The patient group was recruited from among patients who presented to a residential substance abuse treatment facility in Istanbul (Balikli Rum Foundation Hospital). Individuals in the control group were recruited from the same hospital’s staff and their acquaintances. No compensation was given to any participants. Study participants were primarily male (89.8% for the patient group and 91.1% for the control group) and single (73.5% for the patient group and 57.8% for the control group). 2.2. Procedures All patients were substance dependent individuals. To minimize the possible effects of the clinical symptoms that might be associated to early abstinence, all nominees were invited to participate in the study after their detoxification period. Patients who agreed to participate were enrolled in the study on the condition that they fulfilled the inclusion criteria. The criteria were as follows: at least 18 years of age, showing no mental retardation, and demonstrating enough literacy to fill out the measurement instruments. Participants were excluded if they 1) would not commit to future abstinence, 2) were unable to read or speak Turkish, 3) had cognitive difficulties that impaired accurate recall (memory impairment, a diagnosis of schizophrenia, schizoaffective, delusional disorder, or an active psychotic episode), or 4) showed any remaining withdrawal symptoms. After participants read and signed the consent form, they completed the self-report measures. The relevant SCID (Structured Clinical Intervention for DSM-IV) form was used to confirm a clinical diagnosis and to filter the control group for psychiatric diagnoses. All participants were administered a sociodemographic data form, the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (BAI), and the Distress Tolerance Scale (DTS).

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substances used, history of legal involvement, and history of suicidal ideation and attempts. 2.3.2. The Beck Depression Inventory (BDI) This is a 21-item scale measuring emotional, cognitive, somatic and motivational symptoms and is based on data obtained from clinical observations. This Inventory was developed by Beck et al. [21]. In the Turkish version of this test, 17 is considered the cut off point for validity and reliability [22]. 2.3.3. The State Trait Anxiety Inventory (STAI) This scale was developed by Spielberger (1987) [23]. The STAI consists of two sub-scales, each composed of 20-items, measuring state and trait anxiety. The STAI state sub-scale (STAI-S) asks respondents to rate how they feel ‘right now… at this moment’ using a 4-point scale (1 = not at all, 4 = very much so) in response to a series of self-descriptive statements. The STAI trait subscale (STAI-T) asks respondents to rate how they feel ‘in general’ using a 4-point scale (1 = almost never, 4 = almost always) in response to relevant statements (α = 0.90). The Turkish version of the STAI has been demonstrated to be valid and reliable (α = .94) [24]. 2.3.4. The Distress Tolerance Scale (DTS) This scale was created by Simons and Gaher (2005) to measure perceived distress tolerance and the Turkish version’s reliability and validity were demonstrated by Sargin et al. (2012) [2,25]. On the original scale four subscales were proposed, to tolerate emotional distress (measured by the DTS-T with statements like “I can’t handle feeling distressed or upset”), subjective appraisal of distress (measured by the DTS-Ap with statements like “My feelings of distress or being upset are not acceptable”), the attention absorbed by negative emotions (measured by the DTS-Ab with statements like “When I feel distressed or upset, I cannot help but concentrate on how bad the distress actually feels”), and regulation efforts to alleviate distress (measured by the DTS-R with statements like “When I feel distressed or upset I must do something about it immediately”). 2.3.5. The Structured clinical interview for DSM-IV-TR axis I disorders. Non-patient Edition (SCID-I/NP) and Structured clinical interview for DSM-IV axis I disorders. Clinician version (SCID-CV) The clinician version of this instrument was used to make a DSM-IV clinical diagnosis [26]. The non-clinical version was used to rule out any history of Axis I diagnosis in the healthy control group [27].

2.3. Measures

2.4. Procedure

2.3.1. Assessment of demographic information All participants completed a demographics and clinical information form assessing age, marital status, education, and employment status as well as clinical information such as age at first onset of substance use, number and variety of

2.4.1. Statistical procedure The statistical analysis used SPSS 15.0 for windows (SPSS, Chicago, IL). For parametric variables, student t tests were used to compare means, and for the non-parametric tests, the Mann–Whitney U was performed. Frequencies

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Table 1 Sociodemographic variables of the study sample.

Gender Employment status⁎ Civil status Age Education years

Male Female Employed Unemployed Single With partner Mean ± SD Mean ± SD

Table 3 Comparison of the two groups in terms of DTS, BDI, and STAI scores.

Patient (n = 49)

Control group (n = 44)

44 (89, 8%) 5 (10, 2%) 25 (51, 0%) 24 (49, 0%) 36 (73, 5%) 13 (26, 5%) 24, 71 ± 5, 5 10, 47 ± 3, 34

41 (91, 1%) 4 (8, 9%) 36 (80, 0%) 9 (20, 0%) 26 (57, 8%) 19 (42, 2%) 25, 56 ± 6, 9 10,60 ± 3,15

SD = Standard Deviation. ⁎ Statistically significant according to Chi-Square Test.

were analyzed using a Chi-Square test. The Spearman Correlation test was used to correlate variables. The Kolmogorov-Smirnov test was used to examine whether relevant variables were distributed normally.

BDI STAI STAI-S STAI-T DTS-Tot DTS-T DTS-Ab DTS-Ap DTS-R

Patient (n = 49)

Control group (n = 44)

Mean ± SD

Mean ± SD

22,24 87,53 40,76 46,39 40,96 7,55 8,26 18,20 6,93

5,07 70,9 33,31 37,69 54,33 11,51 11,68 21,31 9,82

± ± ± ± ± ± ± ± ±

13,90 18,1 10,80 8,62 13,10 3,38 3,62 5,50 2,76

± ± ± ± ± ± ± ± ±

1,70 15,68 8,98 7,58 9,88 2,49 2,71 3,73 3,35

t value 8,23⁎ 4,72⁎ 3,61⁎ 5,17⁎ −5,54⁎ −6,41⁎ −5,14⁎⁎ −3,17⁎ −4,56⁎

BDI = Beck Depression Inventory, DTS = Distress Tolerance Scale, STAI = State Trait Anxiety Inventory, STAI-S = State Trait Anxiety State Subscale, STAI-T = State, DTS-Tot = Distress Tolerance Test Total score, DTS-T = Distress Tolerance Scale Tolerance subscale, DTS-Ab = Distress Tolerance Scale Absorption subscale, DTS-Ap = Distress Tolerance Scale Appraisal subscale, DTS-R = Distress Tolerance Scale Regulation subscale, SD = Standard Deviation. ⁎ Statistically significant at the level of p b 0.001. ⁎⁎ Statistically significant at the level of p b 0.05.

3. Results The sociodemographic features were similar for substance dependent individuals and controls, with the exception of employment status (see the Table 1). The clinical features of the substance dependent group can be examined on Table 2. It shows these features: the number of substances on which the patient depends, the presence of legal problems, the age that drug use began, and the duration of substance abuse. In the current sample opioid dependency was the most common condition at 40.8% (n = 20), it occurred in conjunction with multiple substance dependency at the same percentage. Twenty four members of the group studied, 48.9%, showed a DSM-IV Axis I disorder in addition to substance dependency. Of this group 8 (16.3%) showed major depressive disorder (MDD), 2 (4%) showed bipolar disorder (PD), 6 (12.2%) showed post traumatic stress disorder, 4 (0.8%) showed panic disorder, 2 (4%) showed obsessive compulsive disorder (OCD), and 1 (2%) showed generalized anxiety disorder. Table 2 Clinical characteristics of the substance-dependent group. Substance use features Substance used

Legal problems Age at substance use onset Substance use duration

Patient (n = 49) Opioid Cannabis Cocaine Multiple Yes No (Mean ± SD) Min-Max (Mean ± SD) Min-Max

SU = Substance Use. SD = Standard Deviation. Min-Max = Minimum and maximum values.

20 (40.8%) 6 (12, 2%) 3 (6, 1%) 20 (40, 8%) 25 (51%) 24 (49%) 17, 43 ± 4 12-30 years old 7 ± 3,85 1-16 years

The substance dependent and healthy control groups were compared in terms of their BDI, STAI, STAI-S, STAI-T, DTS-Tot, DTS-T, DTS-Ab, DTS-Ap, and DTS-R scores. Those variables showed a normal distribution. The means of all scores differed significantly between the two groups at a level of p b 0.001, with the exception of DTS-Ab scores (p b 0.05). The details are shown in Table 3. When the substance dependent group was divided according to whether or not they had an additional Axis I disorder, their BDI, STAI-S, and STAI-T scores differed between the two groups at a level of p ≤ 0.001. Their DTS-Tot, DTS-T, and DTS-Ab scores differed at a level of p b 0.05 (for details please see Table 4). The substance dependent group was divided into two groups according to whether they had a history of legal problems or not. There was no difference on the measures taken between these two groups. Additionally, there were no significant differences in the distress tolerance scores between the single-substance dependent and multiple substance dependent patients (Table 4). The BDI, STAI, STAI-S, STAI-T, DTS-Tot, DTS-T, DTSAb, DTS-Ap, DTS-R scores underwent correlation analysis. All measures (scale total scores and subscales) showed various correlations with each other, with the exception that the BDI scores were not correlated with the DTS_R, and the DTS_Ab with the DTS_R. Details are shown in Table 5. There was no correlation between substance use duration and DTS scores, nor any subscale of the DTS. Additionally, there was no correlation between the age of substance use onset and DTS scores.

4. Discussion The primary aims of this study were to examine DT levels in a substance dependent sample in comparison to a

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Table 4 Comparison of the groups according to different clinical characteristics in substance dependent group. Distress tolerance tables Substance dependent patients, N = 49

BDI STAI-S STAI-T DTS-Tot DTS-T DTS-Ab DTS-Ap DTS-R

Comorbidity Yes (n = 24) Mean ± SD

Comorbidity No (n = 25) Mean ± SD

33.67 47.29 50.50 35.66 5.87 6.95 16.54 6.29

11.28 34.48 42.44 46.04 9.1 9.52 19.80 7.56

± ± ± ± ± ± ± ±

10.26 9.20 7.47 9.28 2.13 3.04 4.27 2.67

± ± ± ± ± ± ± ±

5.41⁎⁎ 8.28⁎⁎ 7.87⁎⁎ 14.35⁎ 3.61⁎ 3.75⁎ 6.14 2.75

Legal problems Yes (n = 25) Mean ± SD

Legal problems No (n = 24) Mean ± SD

23.36 42.36 46.92 38.04 6.92 7.44 16.96 7.16

21,08 39.08 45.83 44.0 8.20 9.12 19.50 6.72

± ± ± ± ± ± ± ±

14.18 11.29 9.15 10.44 2.95 2.88 4.09 2.85

± ± ± ± ± ± ± ±

13,79 11.29 8.19 15.02 3.72 4.15 6.50 2.71

Single substance (n = 29) Mean ± SD 20.17 39.24 44.72 42.37 7.93 8.41 18.58 7.44

± ± ± ± ± ± ± ±

Multiple substance (n = 20) Mean ± SD

12.35 10.36 7.32 12.67 3.22 3.12 5.62 2.65

25.25 42.95 48.80 38.90 7.00 8.05 17.65 6.20

± ± ± ± ± ± ± ±

15.69 11.32 9.92 13.76 3.61 4.33 5.43 2.82

BDI = Beck Depression Inventory, DTS = Distress Tolerance Scale, STAI = State Trait Anxiety Inventory, STAI-S = State Trait Anxiety State Subscale, STAI-T = State, DTS-Tot = Distress Tolerance Test Total score, DTS-T = Distress Tolerance Scale Tolerance subscale, DTS-Ab = Distress Tolerance Scale Absorption subscale, DTS-Ap = Distress Tolerance Scale Appraisal subscale, DTS-R = Distress Tolerance Scale Regulation subscale, SD = Standard Deviation. ⁎ Statistically significant at the level of p b 0.05. ⁎⁎ Statistically significant at the level of p ≤ 0.001.

healthy control group and to examine the relationship between DT and substance dependency features and also with anxiety and depressive symptoms. Though research has explored the connection between DT and anxiety and depressive symptomatology, to our knowledge, this is the

first study of substance dependent individuals that examines DT and the associations between DT and anxiety and depressive symptomatology using a case controlled design. Consistent with our expectations, DT scores were significantly lower in the substance dependent individuals that

Table 5 Correlations between DTS (and subscales) scores and BDI, STAI (state and trait) scores. Scales 1-BDI

2-STAI-S

3-STAI-T

4-DTS_T

5-DTS_Ab

6-DTS_Ap

7-DTS_R

8-DTS_Tot

Pearson correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N Pearson correlation Sig. (2-tailed) N

1

2

3

4

5

6

7

8

1

,680⁎⁎ ,000 49 1

,579⁎⁎ ,000 49 ,702⁎⁎ ,000 49 1

−,519⁎⁎ ,000 49 −,499⁎⁎ ,000 49 −,605⁎⁎ ,000 49 1

−,482⁎⁎ ,000 49 −,483⁎⁎ ,000 49 −,541⁎⁎ ,000 49 ,802⁎⁎ ,000 49 1

−,394⁎⁎ ,005 49 −,424⁎⁎ ,002 49 −,581⁎⁎ ,000 49 ,797⁎⁎ ,000 49 ,740⁎⁎ ,000 49 1

−,248 ,086 49 −,395⁎⁎ ,005 49 −,549⁎⁎ ,000 49 ,540⁎⁎ ,000 49 ,347⁎ ,015 49 ,431⁎⁎ ,002 49 1

−,485⁎⁎ ,000 49 −,524⁎⁎ ,000 49 −,666⁎⁎ ,000 49 ,929⁎⁎ ,000 49 ,868⁎⁎ ,000 49 ,922⁎⁎ ,000 49 ,627⁎⁎ ,000 49 1

49 ,680⁎⁎ ,000 49 ,579⁎⁎ ,000 49 −,519⁎⁎ ,000 49 −,482⁎⁎ ,000 49 −,394⁎⁎ ,005 49 −,248 ,086 49 −,485⁎⁎ ,000 49

49 ,702⁎⁎ ,000 49 −,499⁎⁎ ,000 49 −,483⁎⁎ ,000 49 −,424⁎⁎ ,002 49 −,395⁎⁎ ,005 49 −,524⁎⁎ ,000 49

49 −,605⁎⁎ ,000 49 −,541⁎⁎ ,000 49 −,581⁎⁎ ,000 49 −,549⁎⁎ ,000 49 −,666⁎⁎ ,000 49

49 ,802⁎⁎ ,000 49 ,797⁎⁎ ,000 49 ,540⁎⁎ ,000 49 ,929⁎⁎ ,000 49

49 ,740⁎⁎ ,000 49 ,347⁎ ,015 49 ,868⁎⁎ ,000 49

49 ,431⁎⁎ ,002 49 ,922⁎⁎ ,000 49

49 ,627⁎⁎ ,000 49

49

BDI = Beck Depression Inventory, DTS = Distress Tolerance Scale, STAI = State Trait Anxiety Inventory, STAI-S = State Trait Anxiety State Subscale, STAI-T = State, DTS-Tot = Distress Tolerance Test Total score, DTS-T = Distress Tolerance Scale Tolerance subscale, DTS-Ab = Distress Tolerance Scale Absorption subscale, DTS-Ap = Distress Tolerance Scale Appraisal subscale, DTS-R = Distress Tolerance Scale Regulation subscale, SD = Standard Deviation. ⁎ Correlation is significant at the 0.05 level (2-tailed). ⁎⁎ Correlation is significant at the 0.01 level (2-tailed).

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showed higher levels of depressive and anxiety symptoms. Mean scores for the DTS total score and its subscales were lower than had been previously reported for individuals with substance use problems (e.g., DTS total score = 40,96 ± 13,10 for the current study versus 52.95 ± 13.8 or 47.6 ± 13.87 for the previous two reports on individuals with substance use problems) [7,20]. In addition, the levels of DT in the current study were lower than in a sample of individuals diagnosed with various anxiety disorders (e.g., DTS total score = 40.96 ± 13.10 for the current study versus 48.58 ± 11.48) [13]. Substance dependency is a highly frustrating state, so the very low DT levels that we observed accompanied by high anxiety and depressive symptoms present no surprise. However, while groups with single substance dependency and multiple-substance dependency diagnoses did not differ in their DT levels, substance dependent patients with co-morbid psychiatric disorders and without co-morbid psychiatric disorders did differ. This suggests that substance dependency can be clearly connected with very low DT levels. In addition psychiatric co-morbidity made a difference primarily with psychiatric symptoms like depression and anxiety. There were also significant differences in general DT levels, perceived distress tolerance, and absorption with distress between the two groups. According to the DTS scores reported by Leyro et al. (2011) fewer years of being a smoker was related to a tendency to accept negative emotional states. However, this was not the case for the substance dependent group in the current study, our results are in accord with some prior research [8]. Kaiser et al. found that low distress tolerance and neuroticism were not predictive, but instead impulsive responses to negative affect were stronger predictive factors for substance use problems [8]. In addition, substance misuse and substance dependency are different categorical states rather than states that can be considered to be on a continuum. From the time that low levels of DT were considered relevant in the development and maintenance of substance use, methods to boost DT levels have been proposed as treatments for substance dependence problems [28]. Although this approach has some empirical support [7], it is not clearly established that DT is a primary factor for change in the treatment of substance use problems. However the very low DT levels in this study suggest, at least to us, that DT could be an important realm for intervention. It seems however, that DT is not an independent psychological construct separable from depressive and anxiety, especially trait anxiety, symptoms. High correlations between the DT scale scores and trait anxiety measurements (r = −.666) and their gradual reduction for state anxiety (DT x STAI-S, r = −.524) and depressive symptoms (DT x BDI r = .485) tend to support this claim. These findings should be considered in the light of certain limitations. The relatively small sample size is a limitation that may make generalizing our results difficult. Male gender

dominance of the study group should also be considered when the conclusions are drawn. Although very high gender ratio in favor of males (i.e., 88.3/11.7) was reported in a Turkish sample consisting of substance dependent/abuser patients [29], epidemiological studies revealed relatively modest gender dominance in favor of males for substance dependency prevalence [30,31]. This discrepancy can be caused by different treatment seeking attitudes of the substance-dependent patients in clinical and community samples. Another limitation is the cross-sectional design so that it is impossible to pursue individual’s DT alterations, if any, over the course of the dependency process. Additionally, because of the small sample size, further analysis could not be performed considering co-morbid conditions and substances used. Because the current study sample consisted primarily of opioid dependent and multiple substance dependent patients, it is hard to determine whether our results could be related with opioid dependency or substance dependency more generally. These results are consistent with the idea that distress tolerance is a factor highly related to negative emotional problems like depression and anxiety symptoms, rather than a specific factor for substance dependence problems. Contributors K. Özdel & S. Ekinci designed the study. K. Özdel wrote the first draft of the paper and conducted all statistical analyses and wrote the statistical sections of the paper. S. Ekinci assisted with manuscript revisions. Conflict of interest The authors have no conflicts to declare. Acknowledgment The authors gratefully acknowledge Ms. S. Özdel for managing recruitment and data collection. References [1] Simons JS, Gaher RM. The Distress Tolerance Scale: Development and Validation of a Self-Report Measure. Motiv Emot 2005;29(2): 83-102. [2] Leyro TM, Bernstein A, Vujanovic AA, McLeish AC, Zvolensky MJ. Distress Tolerance Scale: A Confirmatory Factor Analysis Among Daily Cigarette Smokers. J Psychopathol Behav Assess 2011;33(1): 47-57. [3] Özdel K, Alkar ÖY, Taymur I, Türkçapar MH, Zamki E, Sargin AE. Discomfort Intolerance Scale: A Study of Reliability and Validity. JCBPR 2012;1(1):52-8. [4] Linehan MM. Skills training manual for treating borderline personality disorder. In: & Frances A, editor. New York, London: Guilford Press; 1993. [5] Dimeff L, Linehan MM. Dialectical Behavior Therapy in a Nutshell. Calif Psychol 2001;34(3):1-3.

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