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withstanding behaviors in college-aged heavy drinkers
Personality and Individual Differences 111 (2017) 1–5
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How do you restrain yourself from avoidance when distressed? Distress tolerance and affective associations of avoidance/withstanding behaviors in college-aged heavy drinkers Jang-Won Seo ⁎ Department of Psychology, Chonbuk National University, Jeonju, Republic of Korea
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Article history: Received 18 October 2016 Received in revised form 25 January 2017 Accepted 31 January 2017 Available online xxxx Keywords: Distress tolerance Affect Judgment Heavy drinking Ecological momentary assessment
a b s t r a c t Distress tolerance (DT) has been considered an important contributor to manifestation, maintenance, and relapse of alcohol use problems. However, factors that could influence DT among heavy drinkers are unclear. The current study examined the role of affects linked to avoidance/withstanding behavioral options in deciding whether to withstand distressful experiences with a sample of heavy drinkers. To this end, the author administered a well-validated instrument to assess implicit affective associations of avoidance/withstanding options to 36 heavy drinkers and conducted ecological momentary assessment to measure DT of the participants for one week. Multilevel model analyses revealed that affects linked to avoidance/withstanding options were closely related to DT. Affects linked to avoidance/withstanding options could influence DT in heavy drinkers and warrant further exploration. © 2017 Published by Elsevier Ltd.
1. Introduction Many people drink alcohol to reduce feelings of distress (Carpenter & Hasin, 1999; Stockwell, Hodgson, & Rankin, 1982). The amount and frequency of drinking can vary depending on a person's ability to withstand distress. Distress tolerance (DT), the capacity to withstand aversive experiential states, has been considered an important contributor to the manifestation, maintenance, and relapse of alcohol use problems (Gorka, Ali, & Daughters, 2012). However, there are only few theoretical/empirical studies investigating factors that could influence DT in those with alcohol problems. A promising theoretical model of DT that describes hypothetical mechanisms underlying the process of withstanding distress was proposed by Trafton and Gifford (2011). According to them, DT can be defined as the ability to inhibit responding to a behavioral option that could reduce distress immediately (i.e., an immediate negative reinforcement (NR) opportunity) during distressful states. While experiencing distress, people estimate the expected punishments (EP) of responding to an NR opportunity and the expected rewards (ER) of not responding. The results of these estimations could influence the decision of whether to withstand the distress or not. If someone estimates the EP of responding to an NR opportunity and the ER of not responding
⁎ Corresponding author at: Department of Psychology, Chonbuk National University, 567 Baekje-daero, Jeonju-si, Jeollabuk-do, Republic of Korea. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.paid.2017.01.058 0191-8869/© 2017 Published by Elsevier Ltd.
to the opportunity highly, then she/he would decide to withstand distress. One way to assess the ER/EP of an option is to measure the affect linked to that option. According to the literature on the “affect heuristic”, the affective associations of certain options could be used as a heuristic when people estimate ER/EP (Slovic, Finucane, Peters, & MacGregor, 2007). Damasio (1994) also suggested that learning causes certain options to become marked by positive or negative affects and that these affects could be used to predict future outcomes of the options. Similarly, Mowrer (1960) argued that conditioned emotional responses to certain images reflect prospective gains and losses. Thus, the EP of taking an avoidance option (AO; responding to an NR opportunity) and the ER of taking a withstanding option (WO; not responding to an NR opportunity) could be assessed by the positive/negative affects linked to AO and WO (Seo & Kwon, 2016). People could then use these affects to decide whether to withstand distress. A recent study examined the relations between DT and the affects linked to AO/WO in college heavy drinkers (Seo & Kwon, 2016). In this study, the authors differentiated types of AO/WO and DT to examine the relations between DT and the affects linked to AO/WO in a more detailed manner. According to the researchers, there are two types of distressful situations. The first type is when a person performs a distressful task. In this case, the AO would be to stop performing the task (AO-Quitting), the WO would be to continue performing the task (WO-Persevering), and the relevant DT would be the capacity to persevere with the task (DT-Persevering Capacity). The second type is when a person is distressed by negative events but is not performing any
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specific tasks. In this situation, a person would relieve distress by performing specific activities (AO-Relieving), and for heavy drinkers, one of the most salient relieving behaviors would be to drink alcohol (Carpenter & Hasin, 1999; Stockwell et al., 1982). Here, the WO would be to endure without relieving distress (WO-Enduring), and the relevant DT would be the capacity to endure ongoing distress (DT-Enduring Capacity). Hierarchical regression analyses showed that the affects linked to AO-Quitting and WO-Persevering are closely related to DTPersevering Capacity, whereas the affects linked to AO-Relieving and WO-Enduring are associated with DT-Enduring Capacity even after controlling for depression, anxiety, and alcohol use problems of the participants (Seo & Kwon, 2016). The study conducted by Seo and Kwon (2016) is valuable because it was the first trial to examine the relationships between DT and the affects linked to AO/WO. However, there are several concerns that need to be addressed. First, the study relied on participants' self-reports to measure the affects linked to AO/WO. The self-report technique is a common means to assess affective associations of certain concepts or images (Slovic et al., 2007). However, the technique has been criticized for its inability to assess implicit affective associations (Hofmann, Gawronski, Gschwendner, Le, & Schmitt, 2005). Second, the authors used a behavioral task and a self-report measure to assess the two types of DT. Although these instruments have been used in many studies on DT (Leyro, Zvolensky, & Bernstein, 2010), they have some limitations. First, behavioral tasks that assess DT normally use simplified experimental tasks that are quite different from actual tasks in the natural environment. Second, self-report measures can be influenced by recall bias (Shiffman, Stone, & Hufford, 2008). The present study aimed to retest the relations between DT and the affects linked to AO/WO in heavy drinkers using alternative methods that complement shortcomings of the instruments used by Seo and Kwon (2016). First, the Extrinsic Affective Simon Task (EAST; de Houwer, 2003), a common instrument to assess implicit affective associations of certain concepts/images, was used to measure the affects linked to AO/WO. Second, the author used ecological momentary assessment (EMA) to measure DT in the natural environment. EMA involves repeated sampling of current behaviors or experiences in real time; EMA minimizes recall bias and maximizes ecological validity (Shiffman et al., 2008). Based on the results from the prior study, it was expected that the affects linked to AO-Quitting/WO-Persevering would predict DT-Persevering Capacity, while the affects linked to AO-Relieving/WOEnduring would predict DT-Enduring Capacity. 2. Methods 2.1. Participants To recruit participants, advertisements were used in an online research participation system for undergraduates taking psychology classes at a national university in Korea. The minimum drinking level for inclusion in this study was 15 standard drinks per week for men and 12 for women (Wiers & Kummeling, 2004). A typical standard drink contains 10 g of pure ethanol (Miller, Heather, & Hall, 1991). Potential participants were asked about psychiatric history and those who reported any of psychiatric diagnoses were not permitted to participate. Thirty-six (14 women) heavy drinkers were recruited (mean ± standard deviation alcohol use, 31.82 ± 9.14 standard drinks per week) with a mean age of 21.06 ± 2.10 years. The mean score of the Alcohol Use Disorder Identification Test (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) for the sample was 15.17 (SD = 5.12). 2.2. Procedures and measures This study was approved by the university's institutional review board on human subject research. After providing informed consent,
participants were asked to complete the following assessments: (a) an intake lab assessment (measuring alcohol use problems, depression, anxiety, perceived DT, and affective associations of AO/WO) and training on EMA procedures; and (b) a daily assessment of DT for 7 days. Participants received course credit for participating. 2.2.1. Affective associations The EAST was used to assess affects linked to AO/WO. In the EAST, participants evaluate words presented in white by pressing a “good” or “bad” key and respond to colored words with the same keys (e.g., pressing “good” for blue and “bad” for green words). Thus, responses to colored words have an extrinsic response valence and an intrinsic response valence that is evoked by the word itself. Responses for which extrinsic and intrinsic response valence are congruent should be faster than incongruent responses. The EAST has been used in many studies and has good validity (e.g., de Houwer & de Bruycker, 2007). In the current study, the EAST consisted of two practice blocks and subsequent test blocks. In the first practice block, each of the 10 white adjectives (e.g., KIND, HOSTILE) was presented four times in a random order. Participants were instructed to classify the words according to their valence by pressing the P (positive) or Q (negative) key. In the second practice block, each of the four colored words was presented four times in blue and four times in green. Participants were requested to press the P or Q key in response to the color of words (i.e., the P key for blue and the Q key for green). Participants learned the association between blue color and “positive” valence and the link between green color and “negative” valence by performing the two practice blocks. Next, there were four test blocks of 30 trials during which each of the four AO/WO words was presented at least once in each color and each of the 10 adjectives was presented once in white. Participants reported their most distressful life tasks, and these tasks were used for the AO-Quitting/WO-Persevering trials. For example, a participant reported “writing papers” as the most distressful task. In this case, “writing papers” and “quit writing papers” were used for the WO-Persevering trial and the AO-Quitting trial. The author used “drinking” for the AO-Relieving trial and “no drinking” for the WO-Enduring trial. These words were the colored EAST trials. Affects linked to AO/WO were assessed by the response latencies in test trials. For example, the intensity of positive affect associated with AO-Relieving was assessed by the response latency in green trials. As mentioned before, responses for which extrinsic and intrinsic response valence are congruent should be faster than incongruent responses. Thus, it was assumed that participants with high level of positive affect associated with AO-Relieving would take longer time to respond to green trials than those with low level of positive affect linked to AO-Relieving. Next, a composite score of affect was calculated by subtracting the negative affect score from the positive affect score because the positive and negative affect linked to the AO-Relieving were competing with each other. These procedures were repeated for WO-Enduring, AO-Quitting, and WO-Persevering. Finally, an affect index was calculated by subtracting the affect scores of WO from the affect scores of AO because the AO and WO options competed with each other. 2.2.2. Distress tolerance People with high levels of DT withstand distress without drinking for a relatively longer time than those with low levels of DT (e.g., O'Cleirigh, Ironson, & Smits, 2007). Thus, DT-Enduring Capacity was assessed by the time interval between the most distressful life event and a drinking episode. Similarly, people with high levels of DT would continue to perform their distressful tasks for a long time without quitting (e.g., Daughters et al., 2005). DT-Persevering Capacity was assessed by the ratio of the actual amount of time spent on the distressful task to the amount of time allowed to perform the task. The Distress Intolerance Index (DII) was also administered to examine the validity of the two DT indices. The DII is a 10-item questionnaire assessing perceived DT with good reliability and construct validity (McHugh & Otto, 2012).
J.-W. SeoPersonality and Individual Differences 111 (2017) 1–5
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The scale is composed of the items from three DT measures (i.e., Anxiety Sensitivity Index; Peterson & Reiss, 1992; Distress Tolerance Scale; Simons & Gaher, 2005; Frustration-Discomfort Scale; Harrington, 2005) that exhibited the strongest associations with a latent DT factor (McHugh & Otto, 2012). Each item of the scale is scored on a Likerttype scale ranging from 0 (very little) to 4 (very much). In the current study, internal consistency of the scale was good (Cronbach's α = 0.89).
and DT-Persevering Capacity. The seventh version of Hierarchical Linear and Nonlinear Model (HLM 7; Raudenbush, Bryk, & Congdon, 2010) was used for the analyses. Because the two outcome variables did not follow a normal distribution, the two scores were log-transformed before conducting MLM analyses.
2.2.3. Ecological momentary assessments This study included two types of EMA. First, participants were instructed to complete a set of items before each drinking episode (event contingent). They were told to access a website that contained a questionnaire with the items assessing DT-Enduring Capacity and possible confounding variables using their own mobile phones and to fill out the items before they started to drink. The questionnaire consisted of four items: 1) start-time of drinking episode; 2) content and time of the most distressing recent life event and the intensity of negative emotions induced by the event; 3) content of the situational rewards related to WO-Enduring (e.g., emotional supports from family) and the intensity of positive emotions induced by the rewards; and 4) content of the situational punishments related to AO-Relieving (e.g., physical illness) and the intensity of negative emotions induced by the punishments. Each item that assessed the intensity of emotions was rated on a 7point Likert-Type scale ranging from o (very weak) to 6 (very strong). The average time for completing the questionnaire was 3.5 min. Second, participants completed another set of items at the appointed time (10:00 and 22:00) each day (interval contingent). Participants received e-mails twice a day for one week. A short self-report questionnaire was linked to each e-mail. The questionnaire included one item that assessed DT-Persevering Capacity, one item that assessed drinking amount during the last 12 h, and two items that assessed possible confounding variables (i.e., situational rewards/punishments related to WO-Persevering/AO-Quitting such as monetary rewards from parents or impending deadline). Same as the items of the questionnaire for the event-contingent EMA, items that assessed the emotional effect of situational rewards/punishments were rated on a 7-point Likert-type scale. The average time for completing the questionnaire was 3.1 min.
3.1. Preliminary data analyses
2.2.4. Alcohol use, depression, and anxiety The Alcohol Use Disorder Identification Test (AUDIT) is a 10-item questionnaire that is used to assess alcohol-related problems (Saunders et al., 1993). The Center for Epidemiologic Studies Depression Scale (CESD) is a 20-item questionnaire assessing depressive symptoms and has good psychometric properties (Radloff, 1977). The brief version of the State-Trait Anxiety Inventory (STAI-B), a widely used six-item questionnaire assessing anxiety symptoms, was also administered (Marteau & Bekker, 1992). The author included these measures to control for alcohol use problems, depression, and anxiety of participants when examining the relations between DT and the affects linked to AO/WO. 2.3. Statistical analyses Multilevel model (MLM) analyses were used to examine the relations between affects linked to AO/WO and DT. In the present study, multiple observations on DT (Level 1) were nested within participants (Level 2). There were two major outcome variables: DT-Enduring Capacity and DT-Persevering Capacity. Two-level MLM was used to examine the relations between the affects linked to AO-Relieving/WOEnduring and DT-Enduring Capacity. The participant-level (Level 2) variables included depression, anxiety, alcohol use problems, and the affects linked to AO-Relieving/WO-Enduring. Level 1 variables included the effect of situational punishments/rewards associated with AO-Relieving/WO-Enduring and the negative emotions induced by the most distressful life event. Similar procedures were repeated for testing the relations between the affects linked to AO-Quitting/WO-Persevering
3. Results
There were 623 momentary ratings in data analyses, including 119 event-contingent ratings and 504 interval-contingent ratings. Compliance with the study protocol was good; participants completed 94.8% of interval-contingent ratings and filled out event-contingent questionnaires for 91.4% of drinking episodes. Descriptive statistics and intercorrelations are presented in Table 1. The average DT-Enduring Capacity for each participant ranged from 30 min to 300 min, and the average DT-Persevering Capacity for each participant ranged from 0.06 to 0.89. As expected, the two outcome variables were closely related to the DII (r = −0.42, r = −0.41, p b 0.05). 3.2. AO-Relieving/WO-Enduring and DT-Enduring Capacity To control for the intensity of negative affect induced by negative life events and the effect of situational punishments (or rewards) related to “drinking “ (or “no drinking”), the negative affect (NA) scores and situational punishments/rewards (SPR) scores were entered into the level 1 model. DT-Enduring Capacity scores were not associated with NA scores [b(SE) = 12.97(8.36), p = 0.13] or SPR scores [b(SE) = − 0.98(4.04), p = 0.81]. The CESD, STAI-B, and AUDIT were entered into the level 2 model to control for the effects of depression, anxiety, and alcohol use problems. The second model showed better fit to the data than the first model (Δχ2 = 88.71, df = 3, p b 0.001). Finally, the affect index calculated by subtracting the affect scores of WO-Enduring from the affect scores of AO-Relieving was entered into the level 2 model. The affect index was associated with DT-Enduring Capacity [b(SE) = − 0.27(0.09), p b 0.01], and this final model showed better fit to the data than the second model (Δχ2 = 5.26, df = 1, p b 0.05). 3.3. AO-Quitting/WO-Persevering and DT-Persevering Capacity Similar to the prior analysis, SPR scores were entered into the level 1 model. DT-Persevering Capacity scores were not associated with SPR scores [b(SE) = 0.0083(0.0083), p = 0.32]. The CESD, STAI-B, and AUDIT were entered into the level 2 model. The second model showed better fit to the data than the first model (Δχ2 = 33.84, df = 3, p b 0.001). Finally, the affect index calculated by subtracting the affect scores of WO-Persevering from the affect scores of AO-Quitting was
Table 1 Intercorrelations and descriptive statistics for study variables (N = 36). Variable
1
2
3
4
5
6
1. AUDIT 2. DT-E (minutes) 3. DT-P 4. CESD 5. STAI-B 6. AI-RE 7. AI-QP M SD
– −0.45⁎ −0.12 0.21 0.20 0.30 0.24 15.17 5.12
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– 0.46⁎⁎ 0.16 0.19 −0.46⁎⁎ −0.30 131.57 102.21
– 0.18 0.19 −0.29 −0.36⁎ 0.28 0.32
– 0.57⁎⁎ −0.14 −0.07 14.25 7.65
– −0.09 0.01 7.06 3.48
– 0.49⁎⁎ – 20.57 0.79 102.52 108.11
AUDIT = Alcohol Use Disorder Identification Test; DT-E = Distress Tolerance-Enduring Capacity; DT-P = Distress Tolerance-Persevering Capacity; CESD = Center for Epidemiologic Studies Depression Scale; STAI-B = State-Trait Anxiety Inventory-Brief; AI-RE = Affect Index-Relieving/Enduring; AI-QP = Affect Index-Quitting/Persevering. ⁎ p b 0.05. ⁎⁎ p b 0.01.
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J.-W. SeoPersonality and Individual Differences 111 (2017) 1–5
entered into the level 2 model. The affect index was associated with DTPersevering Capacity [b(SE) = − 0.0007(0.0002), p b 0.01], and this final model showed better fit to the data than the second model (Δχ2 = 7.13, df = 1, p b 0.01). 4. Discussion The current study examined the relationships between DT and the affects linked to AO/WO using the EAST and EMA. The affects linked to AO-Quitting/WO-Persevering were related to DT-Persevering Capacity, and the affects linked to AO-Relieving/WO-Enduring were closely associated with DT-Enduring Capacity. These findings suggest that judgments based on affective associations of AO/WO could influence the degree to which heavy drinkers can withstand distress. These results verify the hypothesis proposed by Trafton and Gifford (2011) and support the affective judgment model of DT proposed by Seo and Kwon (2016). Especially, the results from the current study suggest that not only DT in the lab environment but also DT in the natural environment could be influenced by the affects linked to AO/WO. Moreover, the findings provide insight into the relationships among DT, alcohol use problems, and other drinking-related constructs such as impulsivity and coping motives. Prior studies on DT in heavy drinkers reported that impulsivity is closely associated with DT and alcohol use problems (e.g., Marshall-Berenz, Vujanovic, & MacPherson, 2011). In addition, it was suggested that alcohol use coping motives mediate the relationship between DT and drinking problems (Williams, Vik, & Wong, 2015). The findings of the present study could be integrated with the results from the prior studies in several ways. First, impulsivity could influence DT through enhancing the intensity of positive affect associated with AO. Persons with high impulsivity are prone to take avoidance options immediately when distressed because they tend to feel urgency to reduce tension during distressful situations (Whiteside & Lynam, 2001) and they are likely to discount delayed rewards or punishments (Bickel & Marsch, 2001; Dennhardt & Murphy, 2011). Because taking avoidance options such as drinking alcohol during distressful situations reduce tension or induce relief, the options might become marked by positive affect. In this way, impulsivity could be related to DT. Second, alcohol use coping motives might be closely related to positive affect associated with drinking behaviors in heavy drinkers. Alcohol use coping motives are motives to cope with life stress by drinking alcohol. Persons with high level of alcohol use coping motives might have good feelings about drinking because they believe that drinking is useful to reduce painful life stress (Kuntsche, Knibbe, Gmel, & Engels, 2005). However, affective associations of AO could influence both DT and alcohol use coping motives. Thus, the relationships among the three constructs should be explored in future research. The current findings also provide some preliminary evidence for development of DT enhancement interventions that change affective associations of AO/WO. More specifically, classical affective conditioning using words or images that are associated with strong positive/negative affect could be used to change affect linked to AO/WO (e.g., Dijksterhuis, 2004). Another means to change affective associations of AO/WO is inducing positive/negative emotions using actual rewards or punishments. For example, a reward could be given to induce positive emotions after an individual takes WO during distressful situations. In this way, WO would become marked by positive affect. The interventions based on these principles could be used to change affective associations of AO/WO and enhance DT among heavy drinkers. Several limitations of this study should be noted. First, DT-Enduring Capacity was assessed by the time interval between the drinking episode and the most distressful life event. This index was used because the urge to avoid distress would be highest when the most distressful life event occurs. However, it is possible that minor negative events occur after the most distressful event and that the distress induced by these events is added to the existing distress. In this case, the DT-Enduring Capacity of the participant could be underestimated. Therefore,
future research should address this issue by measuring the effect of additional minor negative events. Another concern about the DT-Enduring Capacity index is related to the effect of distressful life events for the past few days on participants' mood. In this study, the author only considered the most distressful events during the time period before each drinking episode on the same day. However, participants might be influenced by negative events for the past few days. Although thoughts or memories related to past negative events that could induce negative emotions were included into the most distressful events, it is still possible that participants could not aware of the lasting effect of prior distressful life events on them. Thus, future research needs to assess the effect of negative events for the past few days on DT-Enduring Capacity index. Another means to overcome the limitation could be measuring changes in distress among participants using more sophisticated instruments including physiological measures. Second, although EMA was used to reduce memory bias, the author still relied on participants' reports to assess the intensity of negative emotions induced by the distressful life events and the time spent performing the distressful task. Thus, the effect of memory bias could not be fully excluded. Third, the procedure of the event-contingent EMA could influence actual drinking behaviors. Although the questionnaire used for the event-contingent EMA was short and participants did not need to put much effort to finish the questionnaire, it is possible that the process of accessing and completing the questionnaire interrupt drinking sequence. In this way, the event-contingent EMA procedure itself might decrease urges or cravings to drink alcohol. However, the frequency and amounts of drinking in participants during EMA were not significantly different from before the EMA procedure, which indicates that the effect of the event-contingent EMA procedure on actual drinking behaviors was negligible. Another issue related to the event-contingent EMA is adoptability of the method to clinical samples. Although participants of the current study showed heavy drinking problems, they maintained certain level of ability to control their behaviors to complete their tasks. This might be the reason why compliance of the event-contingent EMA was high in this study. Clinical groups with severe drinking problems, however, could not follow the protocol of this study as participants of the current study did because they might forget the whole procedure and only concentrate on relieving their cravings by drinking alcohol. Thus, another mode of assessment needs to be developed for clinical samples with severe drinking problems in future research. Fourth, only a small college student sample with heavy drinking problems was used in this study. Thus, the findings should be interpreted within this demographic only and should be replicated with other samples. Despite these limitations, the current study used EMA to produce the first empirical test of the hypotheses proposing the affects linked to AO/ WO as an important contributor to the capacity to withstand distress in daily life among heavy drinkers. In addition, this study used a well-validated instrument to assess affective associations of AO/WO instead of self-report measures. The findings could be an important starting point for further explorations about affective factors that contribute to DT in heavy drinkers.
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Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
How do you restrain yourself from avoidance when distressed? Distress tolerance and affective associations of avoidance/withstanding behaviors in college-aged heavy drinkers Jang-Won Seo ⁎ Department of Psychology, Chonbuk National University, Jeonju, Republic of Korea
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Article history: Received 18 October 2016 Received in revised form 25 January 2017 Accepted 31 January 2017 Available online xxxx Keywords: Distress tolerance Affect Judgment Heavy drinking Ecological momentary assessment
a b s t r a c t Distress tolerance (DT) has been considered an important contributor to manifestation, maintenance, and relapse of alcohol use problems. However, factors that could influence DT among heavy drinkers are unclear. The current study examined the role of affects linked to avoidance/withstanding behavioral options in deciding whether to withstand distressful experiences with a sample of heavy drinkers. To this end, the author administered a well-validated instrument to assess implicit affective associations of avoidance/withstanding options to 36 heavy drinkers and conducted ecological momentary assessment to measure DT of the participants for one week. Multilevel model analyses revealed that affects linked to avoidance/withstanding options were closely related to DT. Affects linked to avoidance/withstanding options could influence DT in heavy drinkers and warrant further exploration. © 2017 Published by Elsevier Ltd.
1. Introduction Many people drink alcohol to reduce feelings of distress (Carpenter & Hasin, 1999; Stockwell, Hodgson, & Rankin, 1982). The amount and frequency of drinking can vary depending on a person's ability to withstand distress. Distress tolerance (DT), the capacity to withstand aversive experiential states, has been considered an important contributor to the manifestation, maintenance, and relapse of alcohol use problems (Gorka, Ali, & Daughters, 2012). However, there are only few theoretical/empirical studies investigating factors that could influence DT in those with alcohol problems. A promising theoretical model of DT that describes hypothetical mechanisms underlying the process of withstanding distress was proposed by Trafton and Gifford (2011). According to them, DT can be defined as the ability to inhibit responding to a behavioral option that could reduce distress immediately (i.e., an immediate negative reinforcement (NR) opportunity) during distressful states. While experiencing distress, people estimate the expected punishments (EP) of responding to an NR opportunity and the expected rewards (ER) of not responding. The results of these estimations could influence the decision of whether to withstand the distress or not. If someone estimates the EP of responding to an NR opportunity and the ER of not responding
⁎ Corresponding author at: Department of Psychology, Chonbuk National University, 567 Baekje-daero, Jeonju-si, Jeollabuk-do, Republic of Korea. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.paid.2017.01.058 0191-8869/© 2017 Published by Elsevier Ltd.
to the opportunity highly, then she/he would decide to withstand distress. One way to assess the ER/EP of an option is to measure the affect linked to that option. According to the literature on the “affect heuristic”, the affective associations of certain options could be used as a heuristic when people estimate ER/EP (Slovic, Finucane, Peters, & MacGregor, 2007). Damasio (1994) also suggested that learning causes certain options to become marked by positive or negative affects and that these affects could be used to predict future outcomes of the options. Similarly, Mowrer (1960) argued that conditioned emotional responses to certain images reflect prospective gains and losses. Thus, the EP of taking an avoidance option (AO; responding to an NR opportunity) and the ER of taking a withstanding option (WO; not responding to an NR opportunity) could be assessed by the positive/negative affects linked to AO and WO (Seo & Kwon, 2016). People could then use these affects to decide whether to withstand distress. A recent study examined the relations between DT and the affects linked to AO/WO in college heavy drinkers (Seo & Kwon, 2016). In this study, the authors differentiated types of AO/WO and DT to examine the relations between DT and the affects linked to AO/WO in a more detailed manner. According to the researchers, there are two types of distressful situations. The first type is when a person performs a distressful task. In this case, the AO would be to stop performing the task (AO-Quitting), the WO would be to continue performing the task (WO-Persevering), and the relevant DT would be the capacity to persevere with the task (DT-Persevering Capacity). The second type is when a person is distressed by negative events but is not performing any
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specific tasks. In this situation, a person would relieve distress by performing specific activities (AO-Relieving), and for heavy drinkers, one of the most salient relieving behaviors would be to drink alcohol (Carpenter & Hasin, 1999; Stockwell et al., 1982). Here, the WO would be to endure without relieving distress (WO-Enduring), and the relevant DT would be the capacity to endure ongoing distress (DT-Enduring Capacity). Hierarchical regression analyses showed that the affects linked to AO-Quitting and WO-Persevering are closely related to DTPersevering Capacity, whereas the affects linked to AO-Relieving and WO-Enduring are associated with DT-Enduring Capacity even after controlling for depression, anxiety, and alcohol use problems of the participants (Seo & Kwon, 2016). The study conducted by Seo and Kwon (2016) is valuable because it was the first trial to examine the relationships between DT and the affects linked to AO/WO. However, there are several concerns that need to be addressed. First, the study relied on participants' self-reports to measure the affects linked to AO/WO. The self-report technique is a common means to assess affective associations of certain concepts or images (Slovic et al., 2007). However, the technique has been criticized for its inability to assess implicit affective associations (Hofmann, Gawronski, Gschwendner, Le, & Schmitt, 2005). Second, the authors used a behavioral task and a self-report measure to assess the two types of DT. Although these instruments have been used in many studies on DT (Leyro, Zvolensky, & Bernstein, 2010), they have some limitations. First, behavioral tasks that assess DT normally use simplified experimental tasks that are quite different from actual tasks in the natural environment. Second, self-report measures can be influenced by recall bias (Shiffman, Stone, & Hufford, 2008). The present study aimed to retest the relations between DT and the affects linked to AO/WO in heavy drinkers using alternative methods that complement shortcomings of the instruments used by Seo and Kwon (2016). First, the Extrinsic Affective Simon Task (EAST; de Houwer, 2003), a common instrument to assess implicit affective associations of certain concepts/images, was used to measure the affects linked to AO/WO. Second, the author used ecological momentary assessment (EMA) to measure DT in the natural environment. EMA involves repeated sampling of current behaviors or experiences in real time; EMA minimizes recall bias and maximizes ecological validity (Shiffman et al., 2008). Based on the results from the prior study, it was expected that the affects linked to AO-Quitting/WO-Persevering would predict DT-Persevering Capacity, while the affects linked to AO-Relieving/WOEnduring would predict DT-Enduring Capacity. 2. Methods 2.1. Participants To recruit participants, advertisements were used in an online research participation system for undergraduates taking psychology classes at a national university in Korea. The minimum drinking level for inclusion in this study was 15 standard drinks per week for men and 12 for women (Wiers & Kummeling, 2004). A typical standard drink contains 10 g of pure ethanol (Miller, Heather, & Hall, 1991). Potential participants were asked about psychiatric history and those who reported any of psychiatric diagnoses were not permitted to participate. Thirty-six (14 women) heavy drinkers were recruited (mean ± standard deviation alcohol use, 31.82 ± 9.14 standard drinks per week) with a mean age of 21.06 ± 2.10 years. The mean score of the Alcohol Use Disorder Identification Test (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) for the sample was 15.17 (SD = 5.12). 2.2. Procedures and measures This study was approved by the university's institutional review board on human subject research. After providing informed consent,
participants were asked to complete the following assessments: (a) an intake lab assessment (measuring alcohol use problems, depression, anxiety, perceived DT, and affective associations of AO/WO) and training on EMA procedures; and (b) a daily assessment of DT for 7 days. Participants received course credit for participating. 2.2.1. Affective associations The EAST was used to assess affects linked to AO/WO. In the EAST, participants evaluate words presented in white by pressing a “good” or “bad” key and respond to colored words with the same keys (e.g., pressing “good” for blue and “bad” for green words). Thus, responses to colored words have an extrinsic response valence and an intrinsic response valence that is evoked by the word itself. Responses for which extrinsic and intrinsic response valence are congruent should be faster than incongruent responses. The EAST has been used in many studies and has good validity (e.g., de Houwer & de Bruycker, 2007). In the current study, the EAST consisted of two practice blocks and subsequent test blocks. In the first practice block, each of the 10 white adjectives (e.g., KIND, HOSTILE) was presented four times in a random order. Participants were instructed to classify the words according to their valence by pressing the P (positive) or Q (negative) key. In the second practice block, each of the four colored words was presented four times in blue and four times in green. Participants were requested to press the P or Q key in response to the color of words (i.e., the P key for blue and the Q key for green). Participants learned the association between blue color and “positive” valence and the link between green color and “negative” valence by performing the two practice blocks. Next, there were four test blocks of 30 trials during which each of the four AO/WO words was presented at least once in each color and each of the 10 adjectives was presented once in white. Participants reported their most distressful life tasks, and these tasks were used for the AO-Quitting/WO-Persevering trials. For example, a participant reported “writing papers” as the most distressful task. In this case, “writing papers” and “quit writing papers” were used for the WO-Persevering trial and the AO-Quitting trial. The author used “drinking” for the AO-Relieving trial and “no drinking” for the WO-Enduring trial. These words were the colored EAST trials. Affects linked to AO/WO were assessed by the response latencies in test trials. For example, the intensity of positive affect associated with AO-Relieving was assessed by the response latency in green trials. As mentioned before, responses for which extrinsic and intrinsic response valence are congruent should be faster than incongruent responses. Thus, it was assumed that participants with high level of positive affect associated with AO-Relieving would take longer time to respond to green trials than those with low level of positive affect linked to AO-Relieving. Next, a composite score of affect was calculated by subtracting the negative affect score from the positive affect score because the positive and negative affect linked to the AO-Relieving were competing with each other. These procedures were repeated for WO-Enduring, AO-Quitting, and WO-Persevering. Finally, an affect index was calculated by subtracting the affect scores of WO from the affect scores of AO because the AO and WO options competed with each other. 2.2.2. Distress tolerance People with high levels of DT withstand distress without drinking for a relatively longer time than those with low levels of DT (e.g., O'Cleirigh, Ironson, & Smits, 2007). Thus, DT-Enduring Capacity was assessed by the time interval between the most distressful life event and a drinking episode. Similarly, people with high levels of DT would continue to perform their distressful tasks for a long time without quitting (e.g., Daughters et al., 2005). DT-Persevering Capacity was assessed by the ratio of the actual amount of time spent on the distressful task to the amount of time allowed to perform the task. The Distress Intolerance Index (DII) was also administered to examine the validity of the two DT indices. The DII is a 10-item questionnaire assessing perceived DT with good reliability and construct validity (McHugh & Otto, 2012).
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The scale is composed of the items from three DT measures (i.e., Anxiety Sensitivity Index; Peterson & Reiss, 1992; Distress Tolerance Scale; Simons & Gaher, 2005; Frustration-Discomfort Scale; Harrington, 2005) that exhibited the strongest associations with a latent DT factor (McHugh & Otto, 2012). Each item of the scale is scored on a Likerttype scale ranging from 0 (very little) to 4 (very much). In the current study, internal consistency of the scale was good (Cronbach's α = 0.89).
and DT-Persevering Capacity. The seventh version of Hierarchical Linear and Nonlinear Model (HLM 7; Raudenbush, Bryk, & Congdon, 2010) was used for the analyses. Because the two outcome variables did not follow a normal distribution, the two scores were log-transformed before conducting MLM analyses.
2.2.3. Ecological momentary assessments This study included two types of EMA. First, participants were instructed to complete a set of items before each drinking episode (event contingent). They were told to access a website that contained a questionnaire with the items assessing DT-Enduring Capacity and possible confounding variables using their own mobile phones and to fill out the items before they started to drink. The questionnaire consisted of four items: 1) start-time of drinking episode; 2) content and time of the most distressing recent life event and the intensity of negative emotions induced by the event; 3) content of the situational rewards related to WO-Enduring (e.g., emotional supports from family) and the intensity of positive emotions induced by the rewards; and 4) content of the situational punishments related to AO-Relieving (e.g., physical illness) and the intensity of negative emotions induced by the punishments. Each item that assessed the intensity of emotions was rated on a 7point Likert-Type scale ranging from o (very weak) to 6 (very strong). The average time for completing the questionnaire was 3.5 min. Second, participants completed another set of items at the appointed time (10:00 and 22:00) each day (interval contingent). Participants received e-mails twice a day for one week. A short self-report questionnaire was linked to each e-mail. The questionnaire included one item that assessed DT-Persevering Capacity, one item that assessed drinking amount during the last 12 h, and two items that assessed possible confounding variables (i.e., situational rewards/punishments related to WO-Persevering/AO-Quitting such as monetary rewards from parents or impending deadline). Same as the items of the questionnaire for the event-contingent EMA, items that assessed the emotional effect of situational rewards/punishments were rated on a 7-point Likert-type scale. The average time for completing the questionnaire was 3.1 min.
3.1. Preliminary data analyses
2.2.4. Alcohol use, depression, and anxiety The Alcohol Use Disorder Identification Test (AUDIT) is a 10-item questionnaire that is used to assess alcohol-related problems (Saunders et al., 1993). The Center for Epidemiologic Studies Depression Scale (CESD) is a 20-item questionnaire assessing depressive symptoms and has good psychometric properties (Radloff, 1977). The brief version of the State-Trait Anxiety Inventory (STAI-B), a widely used six-item questionnaire assessing anxiety symptoms, was also administered (Marteau & Bekker, 1992). The author included these measures to control for alcohol use problems, depression, and anxiety of participants when examining the relations between DT and the affects linked to AO/WO. 2.3. Statistical analyses Multilevel model (MLM) analyses were used to examine the relations between affects linked to AO/WO and DT. In the present study, multiple observations on DT (Level 1) were nested within participants (Level 2). There were two major outcome variables: DT-Enduring Capacity and DT-Persevering Capacity. Two-level MLM was used to examine the relations between the affects linked to AO-Relieving/WOEnduring and DT-Enduring Capacity. The participant-level (Level 2) variables included depression, anxiety, alcohol use problems, and the affects linked to AO-Relieving/WO-Enduring. Level 1 variables included the effect of situational punishments/rewards associated with AO-Relieving/WO-Enduring and the negative emotions induced by the most distressful life event. Similar procedures were repeated for testing the relations between the affects linked to AO-Quitting/WO-Persevering
3. Results
There were 623 momentary ratings in data analyses, including 119 event-contingent ratings and 504 interval-contingent ratings. Compliance with the study protocol was good; participants completed 94.8% of interval-contingent ratings and filled out event-contingent questionnaires for 91.4% of drinking episodes. Descriptive statistics and intercorrelations are presented in Table 1. The average DT-Enduring Capacity for each participant ranged from 30 min to 300 min, and the average DT-Persevering Capacity for each participant ranged from 0.06 to 0.89. As expected, the two outcome variables were closely related to the DII (r = −0.42, r = −0.41, p b 0.05). 3.2. AO-Relieving/WO-Enduring and DT-Enduring Capacity To control for the intensity of negative affect induced by negative life events and the effect of situational punishments (or rewards) related to “drinking “ (or “no drinking”), the negative affect (NA) scores and situational punishments/rewards (SPR) scores were entered into the level 1 model. DT-Enduring Capacity scores were not associated with NA scores [b(SE) = 12.97(8.36), p = 0.13] or SPR scores [b(SE) = − 0.98(4.04), p = 0.81]. The CESD, STAI-B, and AUDIT were entered into the level 2 model to control for the effects of depression, anxiety, and alcohol use problems. The second model showed better fit to the data than the first model (Δχ2 = 88.71, df = 3, p b 0.001). Finally, the affect index calculated by subtracting the affect scores of WO-Enduring from the affect scores of AO-Relieving was entered into the level 2 model. The affect index was associated with DT-Enduring Capacity [b(SE) = − 0.27(0.09), p b 0.01], and this final model showed better fit to the data than the second model (Δχ2 = 5.26, df = 1, p b 0.05). 3.3. AO-Quitting/WO-Persevering and DT-Persevering Capacity Similar to the prior analysis, SPR scores were entered into the level 1 model. DT-Persevering Capacity scores were not associated with SPR scores [b(SE) = 0.0083(0.0083), p = 0.32]. The CESD, STAI-B, and AUDIT were entered into the level 2 model. The second model showed better fit to the data than the first model (Δχ2 = 33.84, df = 3, p b 0.001). Finally, the affect index calculated by subtracting the affect scores of WO-Persevering from the affect scores of AO-Quitting was
Table 1 Intercorrelations and descriptive statistics for study variables (N = 36). Variable
1
2
3
4
5
6
1. AUDIT 2. DT-E (minutes) 3. DT-P 4. CESD 5. STAI-B 6. AI-RE 7. AI-QP M SD
– −0.45⁎ −0.12 0.21 0.20 0.30 0.24 15.17 5.12
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– 0.46⁎⁎ 0.16 0.19 −0.46⁎⁎ −0.30 131.57 102.21
– 0.18 0.19 −0.29 −0.36⁎ 0.28 0.32
– 0.57⁎⁎ −0.14 −0.07 14.25 7.65
– −0.09 0.01 7.06 3.48
– 0.49⁎⁎ – 20.57 0.79 102.52 108.11
AUDIT = Alcohol Use Disorder Identification Test; DT-E = Distress Tolerance-Enduring Capacity; DT-P = Distress Tolerance-Persevering Capacity; CESD = Center for Epidemiologic Studies Depression Scale; STAI-B = State-Trait Anxiety Inventory-Brief; AI-RE = Affect Index-Relieving/Enduring; AI-QP = Affect Index-Quitting/Persevering. ⁎ p b 0.05. ⁎⁎ p b 0.01.
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entered into the level 2 model. The affect index was associated with DTPersevering Capacity [b(SE) = − 0.0007(0.0002), p b 0.01], and this final model showed better fit to the data than the second model (Δχ2 = 7.13, df = 1, p b 0.01). 4. Discussion The current study examined the relationships between DT and the affects linked to AO/WO using the EAST and EMA. The affects linked to AO-Quitting/WO-Persevering were related to DT-Persevering Capacity, and the affects linked to AO-Relieving/WO-Enduring were closely associated with DT-Enduring Capacity. These findings suggest that judgments based on affective associations of AO/WO could influence the degree to which heavy drinkers can withstand distress. These results verify the hypothesis proposed by Trafton and Gifford (2011) and support the affective judgment model of DT proposed by Seo and Kwon (2016). Especially, the results from the current study suggest that not only DT in the lab environment but also DT in the natural environment could be influenced by the affects linked to AO/WO. Moreover, the findings provide insight into the relationships among DT, alcohol use problems, and other drinking-related constructs such as impulsivity and coping motives. Prior studies on DT in heavy drinkers reported that impulsivity is closely associated with DT and alcohol use problems (e.g., Marshall-Berenz, Vujanovic, & MacPherson, 2011). In addition, it was suggested that alcohol use coping motives mediate the relationship between DT and drinking problems (Williams, Vik, & Wong, 2015). The findings of the present study could be integrated with the results from the prior studies in several ways. First, impulsivity could influence DT through enhancing the intensity of positive affect associated with AO. Persons with high impulsivity are prone to take avoidance options immediately when distressed because they tend to feel urgency to reduce tension during distressful situations (Whiteside & Lynam, 2001) and they are likely to discount delayed rewards or punishments (Bickel & Marsch, 2001; Dennhardt & Murphy, 2011). Because taking avoidance options such as drinking alcohol during distressful situations reduce tension or induce relief, the options might become marked by positive affect. In this way, impulsivity could be related to DT. Second, alcohol use coping motives might be closely related to positive affect associated with drinking behaviors in heavy drinkers. Alcohol use coping motives are motives to cope with life stress by drinking alcohol. Persons with high level of alcohol use coping motives might have good feelings about drinking because they believe that drinking is useful to reduce painful life stress (Kuntsche, Knibbe, Gmel, & Engels, 2005). However, affective associations of AO could influence both DT and alcohol use coping motives. Thus, the relationships among the three constructs should be explored in future research. The current findings also provide some preliminary evidence for development of DT enhancement interventions that change affective associations of AO/WO. More specifically, classical affective conditioning using words or images that are associated with strong positive/negative affect could be used to change affect linked to AO/WO (e.g., Dijksterhuis, 2004). Another means to change affective associations of AO/WO is inducing positive/negative emotions using actual rewards or punishments. For example, a reward could be given to induce positive emotions after an individual takes WO during distressful situations. In this way, WO would become marked by positive affect. The interventions based on these principles could be used to change affective associations of AO/WO and enhance DT among heavy drinkers. Several limitations of this study should be noted. First, DT-Enduring Capacity was assessed by the time interval between the drinking episode and the most distressful life event. This index was used because the urge to avoid distress would be highest when the most distressful life event occurs. However, it is possible that minor negative events occur after the most distressful event and that the distress induced by these events is added to the existing distress. In this case, the DT-Enduring Capacity of the participant could be underestimated. Therefore,
future research should address this issue by measuring the effect of additional minor negative events. Another concern about the DT-Enduring Capacity index is related to the effect of distressful life events for the past few days on participants' mood. In this study, the author only considered the most distressful events during the time period before each drinking episode on the same day. However, participants might be influenced by negative events for the past few days. Although thoughts or memories related to past negative events that could induce negative emotions were included into the most distressful events, it is still possible that participants could not aware of the lasting effect of prior distressful life events on them. Thus, future research needs to assess the effect of negative events for the past few days on DT-Enduring Capacity index. Another means to overcome the limitation could be measuring changes in distress among participants using more sophisticated instruments including physiological measures. Second, although EMA was used to reduce memory bias, the author still relied on participants' reports to assess the intensity of negative emotions induced by the distressful life events and the time spent performing the distressful task. Thus, the effect of memory bias could not be fully excluded. Third, the procedure of the event-contingent EMA could influence actual drinking behaviors. Although the questionnaire used for the event-contingent EMA was short and participants did not need to put much effort to finish the questionnaire, it is possible that the process of accessing and completing the questionnaire interrupt drinking sequence. In this way, the event-contingent EMA procedure itself might decrease urges or cravings to drink alcohol. However, the frequency and amounts of drinking in participants during EMA were not significantly different from before the EMA procedure, which indicates that the effect of the event-contingent EMA procedure on actual drinking behaviors was negligible. Another issue related to the event-contingent EMA is adoptability of the method to clinical samples. Although participants of the current study showed heavy drinking problems, they maintained certain level of ability to control their behaviors to complete their tasks. This might be the reason why compliance of the event-contingent EMA was high in this study. Clinical groups with severe drinking problems, however, could not follow the protocol of this study as participants of the current study did because they might forget the whole procedure and only concentrate on relieving their cravings by drinking alcohol. Thus, another mode of assessment needs to be developed for clinical samples with severe drinking problems in future research. Fourth, only a small college student sample with heavy drinking problems was used in this study. Thus, the findings should be interpreted within this demographic only and should be replicated with other samples. Despite these limitations, the current study used EMA to produce the first empirical test of the hypotheses proposing the affects linked to AO/ WO as an important contributor to the capacity to withstand distress in daily life among heavy drinkers. In addition, this study used a well-validated instrument to assess affective associations of AO/WO instead of self-report measures. The findings could be an important starting point for further explorations about affective factors that contribute to DT in heavy drinkers.
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