Journal of Affective Disorders 300 (2022) 492–504

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Distress tolerance across substance use, eating, and borderline personality

disorders: A meta-analysis
Sophie Mattingley a, George J. Youssef a, b, e, Victoria Manning c, d, Liam Graeme a, Kate Hall a, b, *
a
Deakin University, Geelong, Australia, School of Psychology
b
Centre for Drug Use, Addictive, and Anti-social Behaviour Research (CEDAAR), Deakin University, Australia
c
Monash Addiction Research Centre (MARC), Eastern Health Clinical School, Monash University, Australia
d
Turning Point, Eastern Health, Australia
e
Centre for Adolescent Health, Murdoch Children’s Research Institute, Parkville, VIC, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Distress tolerance (DT) has received increased attention in recent years due to its purported role in
Distress tolerance dysregulated behaviours and their clinical manifestations, such as problematic substance use (PSU), disordered
Problematic substance use eating behaviours (e.g., binge-eating and purging; DEB), and borderline personality disorder (BPD) symptom­
Disordered eating
atology. Despite the proposed transdiagnostic utility of DT across PSU, DEB, and BPD, there has yet to be a
Borderline personality disorder
systematic and comprehensive examination characterising and comparing its association with this class of
Transdiagnostic
impulsive-type psychopathology.
Methods: A systematic search was conducted across five electronic databases using search terms designed to
capture extant literature on the association between DT and PSU, DEB, and BPD symptomatology. A series of
meta-analyses were undertaken on correlation coefficients from 81 studies to examine the association between
DT and each psychopathology domain, as well as impulsive-type psychopathology overall. Moderator analyses
were conducted to examine whether these relationships were moderated by DT measurement type, sample type,
age, and gender.
Results: DT shared significant, negative, medium correlations with PSU (r = –.18,), DEB (r = –.20), and BPD
symptomatology (r = –.27). The magnitude of these associations was not significantly different across the three
psychopathology domains, supporting transdiagnostic conceptualisation. DT measurement type, age, and sample
type moderated several of these indicated relationships.
Limitations: The majority of studies were conducted in adult samples from Western countries, limiting under­
standing of these relationships across development and different cultures.
Conclusions: The present findings support the putative transdiagnostic role of DT across PSU, DEB, and BPD,
which may ultimately inform novel, cross-cutting interventions.

1. Introduction both concurrent and lifetime comorbidity (Bahji et al., 2019; Khosravi,
2020; Trull et al., 2018). Around half of those with BPD also have an
Substance use disorders (SUDs), eating disorders characterised by SUD, and around a quarter of those with an SUD also meet criteria for
binge-eating and purging (EDs-B/P) and borderline personality disorder BPD (Trull et al., 2018). Additionally, EDs-B/P have higher rates of
(BPD) represent a uniquely harmful and complex group of psychological comorbidity with both SUDs and BPD than eating disorders without
disorders. Common across these disorders is an underlying pattern of binge-eating or purging (Bahji et al., 2019), further highlighting a po­
harmful impulsivity and behavioural dysregulation (Martin et al., 2014; tential role for underlying impulsivity in explaining this co-occurrence.
Tomko et al., 2014; Winkler et al., 2014), and through a transdiagnostic These patterns of comorbidity amplify the harm experienced by the
lens these disorders may be considered to constitute a cluster of individual and raise fundamental questions surrounding the utility of
impulsive-type psychopathology (Gillan and Seow, 2020). Relatedly, ‘gold standard’, disorder-specific interventions (Martin et al., 2018).
within this cluster of psychopathology lies marked overlap in terms of In recent years, such questioning has led to the proliferation of

* Corresponding author at: School of Psychology, Deakin University, Burwood, VIC, Australia.
E-mail address: [email protected] (K. Hall).

https://doi.org/10.1016/j.jad.2021.12.126
Received 5 July 2021; Received in revised form 8 November 2021; Accepted 30 December 2021
Available online 2 January 2022
0165-0327/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Mattingley et al. Journal of Affective Disorders 300 (2022) 492–504

transdiagnostic approaches to impulsive-type psychopathology, which alcohol use problems in a sample of undergraduates (Buckheit et al.,
have been argued to promise a more efficient and externally valid form 2019). Additionally, another study found that problematic alcohol use
of intervention by cross-cutting common or core mechanisms underlying was significantly associated with self-reported but not behavioural
symptomatology (Eaton et al., 2015; Marchette and Weisz, 2017; Martin measures of DT (Holzhauer et al., 2017). Given abiding interest in DT as
et al., 2018). One psychological construct receiving increased attention an aetiological mechanism and treatment target for PSU (e.g., Borno­
in relation to this emerging framework is distress tolerance (DT), defined valova et al., 2012; Warner and Murphy, 2021), clarification of these
as an individual’s capacity to withstand negative affect (Leyro et al., mixed findings through a systematic and comprehensive review of the
2010). Both self-report (i.e., perceived DT) and behavioural (i.e., literature on the relationship between DT and PSU is needed.
demonstrated capacity to tolerate distress) indices have been used to
measure DT, with each measurement category encompassing several 1.2. Distress tolerance and disordered eating behaviours
variants. Despite focused efforts to resolve DT measurement heteroge­
neity (e.g., Bernstein et al., 2009; McHugh and Otto, 2012), researchers DEB, such as binge-eating and purging, are another prominent area
have continued to use a variety of DT measures to examine its rela­ in which emotion regulatory processes have been considered key to the
tionship with psychopathology. pathogenesis of behavioural dysregulation. Research suggests that a
Indeed, studies have shown low DT (i.e., distress intolerance) to be prominent reason for engaging in DEB is the expectation that these be­
associated with wide-ranging psychopathology, including SUDs haviours will help to alleviate negative affect (De Young et al., 2014;
(McHugh and Kneeland, 2019), eating disorders (Lampard et al., Fischer et al., 2018; Smith et al., 2020). As a result, low DT has become a
2011a), BPD (Kiselica et al., 2014), depressive disorders (Lass and key treatment target across both traditional and novel treatment ap­
Winer, 2020), anxiety disorders (Laposa et al., 2015), proaches for EDs-B/P (Fairburn et al., 2003; Juarascio et al., 2017;
obsessive-compulsive disorder (Laposa et al., 2015), and post-traumatic Kamody et al., 2020), and one hypothesised mechanism underpinning
stress disorder (for a systematic review and meta-analysis, see Akbari the co-occurrence between EDs-B/P and other types of impulsive-type
et al., 2021). It has been theorised that deficits in one’s ability to tolerate psychopathology (Kim and Hodgins, 2018). Furthermore, several
negative affect (i.e., low DT) contributes to engagement in maladaptive studies have been dedicated to refining the self-report measurement of
behaviours that function to alleviate psychological discomfort associ­ DT specifically for the purpose of investigating its role in eating disor­
ated with aversive emotional states, thereby strenghtening a negative ders (Corstorphine et al., 2007; Lampard et al., 2011a; Raykos et al.,
feedback loop through which such behaviours are maintained (Leyro 2009). However, consistent with the literature on the relationship be­
et al., 2010; Zvolensky and Hogan, 2013). Despite increasing popularity tween DT and PSU, the emphasis placed on DT in the occurrence of DEB
of interventions designed to target low DT for these behaviours and their has not been supported by robust findings. While several studies have
clinical manifestations (Ritschel et al., 2015; Wright et al., 2020), gaps demonstrated the expected negative association between DT and DEB
remain in our understanding of the unique and shared role of DT across (Anestis et al., 2007, 2012b; Eichen et al., 2017), others have not been
disorders with transdiagnostic relevance, such as in the case of SUDs, able to replicate this relationship (Kelly et al., 2014; Yiu et al., 2018).
EDs-B/P, and BPD (i.e., impulsive-type psychopathology). In particular, Therefore, questions remain regarding the conditions under which an
there has yet to be a systematic and quantitative review clarifying the association between DT and DEB exists. Meta-analysing existing studies
overall magnitude and direction of this relationship both within and of this relationship and examining potential moderators is a suitable
across these diagnostic domains. Furthermore, in spite of the purported next step in addressing this gap in our understanding.
transdiagnostic utility of DT, there is a dearth of studies directly testing
whether its relationship to psychopathology is transdiagnostic in nature; 1.3. Distress tolerance and borderline personality disorder
that is, the degree to which the magnitude and direction of its rela­
tionship is consistent across diagnostic domains. In the current paper, Linehan’s (1993) seminal work on the aetiology and treatment of
we conducted a meta-analysis to summarise and compare the relation­ BPD suggests that DT is one of the core mechanisms underlying BPD
ships between DT and problematic substance use (PSU), disordered pathology. Linehan proposed that, due to a combination of biological
eating behaviours (namely binge-eating and purging; DEB), and emotional sensitivity and an invalidating childhood environment, in­
borderline personality disorder (BPD) symptomatology. However, dividuals with BPD are hindered in their learning of ways to tolerate
below we first present a critical narrative review of the literature on DT distress and, consequently, develop an unwillingness to experience and
in relation to these classes of psychopathology separately to con­ seek ways of avoiding distress. Given the emphasis on DT in this
textualise our research. prominent theoretical model, researchers began to examine the rela­
tionship between DT and BPD symptomatology. Cavicchioli et al. (2015)
1.1. Distress tolerance and problematic substance use conducted a meta-analysis examining the association between BPD
features and experiential avoidance, thought suppression, and distress
Emotion regulatory models of SUDs, alongside the complete sub- intolerance (i.e., low DT), which they conceptualised as three constructs
clinical and clinical continuum of risky substance use and substance- depicting inability to withstand present-moment distress. Five of the 21
related harms (i.e., PSU), posit that some individuals have a predispo­ studies that were meta-analysed, encompassing 1,135 participants,
sition towards using substances as a means of regulating their affect (i.e., examined the relationship between distress intolerance and BPD fea­
reducing negative affect and increasing positive affect) (Kober, 2014). It tures and, as hypothesised, this relationship was found to be charac­
follows that individuals who experience distress as unbearable (i.e., terised by a large, positive association (r = .30) (equating to a large,
individuals with low DT) would be at increased risk of engaging in this negative association with DT). While Cavicchioli et al.’s (2015) research
pathway towards substance use, thus increasing risk towards PSU was novel in its use of meta-analysis to examine this relationship, a
(McHugh and Kneeland, 2019). It is unsurprising, therefore, that much significant limitation was the lack of formal testing to determine the
of the literature exploring the role of DT in psychopathology has focused influence of important factors such as DT measurement type and sample
on PSU. Indeed, many studies have found a negative association be­ type on this relationship. Furthermore, while it offered insight into the
tween DT and PSU in both clinical and non-clinical samples (Buckner relationship between DT and BPD specifically, it does not contribute to
et al., 2016; Bujarski et al., 2012; Gorka et al., 2012), and lower levels of understanding of the transdiagnostic utility of DT. The present study
DT have been found in individuals with SUDs when compared with therefore aims to overcome these limitations by extending the investi­
healthy controls (Özdel and Ekinci, 2014). However, not all studies have gation to other areas of impulsive-type psychopathology and including
replicated this relationship. For example, a recent investigation found more extensive moderator analyses. Furthermore, we focused specif­
that neither behavioural nor self-reported DT significantly predicted ically on DT independently from other theoretically overlapping

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constructs, such as experiential avoidance and thought suppression, due Table 1

to research supporting its uniqueness from these constructs (Juarascio Search Terms Used in Systematic Search.
et al., 2020). Concept Search Terms

Concept 1: Distress OR Discomfort OR N1 Toleran* OR

1.4. Potential moderators in the relationship between distress tolerance Distress Affect* OR Emot* OR Pain OR Intoleran* OR Persist*
and impulsive-type psychopathology tolerance Phys* OR Psych*

Concept 2: Impulsive-type psychopathology

The presence of mixed findings regarding the relationship between
Concept 2a: Substance*; Drug*; Alcohol; N1 “use disorder*”;
DT and PSU, DEB, and BPD symptomatology raises the question of
Problematic Cannabi*; Cocaine; misuse; abuse;
whether their association is only relevant under certain circumstances. substance use Amphetamine*; addiction; “use
For instance, research suggests that DT may function differently Methamphetamine*; Heroin; problem*”;
depending on variables such as age (Rette et al., 2021), gender Opioid*; Opium; Stimulant*; problematic;
Inhalant*; Benzodiazepine*; “problematic use”;
(Daughters et al., 2014), sample type (i.e., whether participants are from
Hallucinogen*; Ecstasy; dependen*
a clinical or non-clinical population; Tonarely and Ehrenreich-May MDMA
2020), and DT measurement type (Glassman et al., 2016). Clarifying Concept 2b: Eating N0 (disorder*; dysfunction*; disturbance*; problem*) OR
these potential moderators may inform targeted DT interventions. In the Disordered (bing*; purg*; bulimi*)
current study, meta-analytic techniques were implemented to directly eating
behaviours
assess whether the statistical significance of the relationships between
Concept 2c: “borderline personality”; “borderline trait*”; BPD
DT and PSU, DEB, and BPD symptomatology, both separately and Borderline
collectively, is dependent on these factors. personality
disorder
1.5. The present study
impulsive-type psychopathology).
In the current study, we aimed to quantitatively summarise and
directly compare the associations between emotional DT and both
clinical and subclinical levels of impulsive-type psychopathology (PSU, 2.3. Study selection
DEB, and BPD symptomatology) by conducting a meta-analysis on this
relationship. In order to summarise and compare disorder-specific as­ Studies identified in the above literature search were first uploaded
sociations, we conducted separate meta-analyses of the correlation co­ into the referencing software Mendeley to undergo de-duplication.
efficients for the relationship between DT and each psychopathology Following removal of duplicates, remaining studies were uploaded to
domain. Additionally, we investigated the overall meta-analytic effect the online application tool Rayyan for title and abstract screening of
across all three psychopathology domains to characterise the trans­ study relevance (Ouzzani et al., 2016). Studies included after this stage
diagnostic relationship between DT and impulsive-type psychopathol­ were exported for full-text screening. Studies were included if they: (i)
ogy. Finally, we explored the influence of several empirically and were peer-reviewed; (ii) were written in English; (iii) included a previ­
clinically relevant variables on this relationship through a series of ously published measure of DT (or distress intolerance) that aligned with
moderation analyses. Specifically, we examined whether the meta- our chosen DT definition (outlined below); (iv) included a validated
analytic relationships between DT and PSU, DEB, and BPD symptom­ measure of one or more of PSU, DEB, and BPD symptomatology or
atology (separately and collectively) were moderated by measurement features; and (v) examined and reported on the relationship between DT
type (self-report vs. behavioural), sample type (clinical vs. non-clinical), (or distress intolerance) and the relevant PSU, DEB, and/or BPD measure
sample age (adolescent vs. young adult vs. adult), and gender (whether (s), or provided data from which this relationship could be calculated.
the sample was predominantly female, predominantly male, or For the purposes of this study, DT was defined as both a) the perceived
balanced). capacity to withstand negative or aversive emotional discomfort and b)
the behaviour of withstanding or persisting with emotional discomfort
2. Method elicited by an external stressor (Leyro et al., 2010). Studies were
excluded if they: (i) only measured tolerance for physical pain or
2.1. Protocol discomfort; (ii) measured tolerance for specific emotional states as
opposed to general distress (e.g., anxiety sensitivity, intolerance of un­
This meta-analysis was undertaken in accordance with the PRISMA certainty); (iii) measured tobacco smoking but no other PSU outcomes;
guidelines (Preferred Reporting Items for Systematic Reviews and Meta- or (iv) measured substance consumption but not PSU. Our decision to
Analyses; Moher et al., 2009), where applicable. The protocol was excluded smoking studies was due to this literature having recently been
pre-registered with PROSPERO, an international prospective register of summarised elsewhere (Veilleux, 2019). Validation screening of 10% of
systematic reviews (project ID: CRD42018102460). studies at the title and abstract stage, and 20% of studies at the full-text
stage, was completed by the fourth author. Inter-rater reliability was
2.2. Search strategy calculated using prevalence-adjusted bias-adjusted kappa (PABAK; Byrt
et al., 1993). Studies for which there were discrepancies between the
A literature search was conducted across five electronic databases: first and fourth authors’ decision-making were reviewed until a mutual
PsycINFO, MEDLINE Complete, PsycArticles, Psychology and behav­ conclusion was reached regarding study eligibility. Additionally, a
ioral Sciences Collection, and SocINDEX. Database limiters were used to meeting was held between the first, second, and last author in which the
refine the searches to: (i) peer reviewed studies; (ii) studies published in item and scale-level content of DT measures used across studies was
English; and (iii) human studies. Search terms used in the systematic discussed to determine whether they aligned with our chosen definition
search are shown in Table 1. We replicated the DT search terms used in of DT.
the widely cited narrative review of DT and psychopathology by Leyro
et al. (2010) to assure adequate breadth of DT terminology. Boolean 2.4. Quality assessment
operators (e.g., ‘OR’; ‘N1’) and brackets were used around search terms
to expand and refine the search as needed. As a final step, we used the In line with the PRISMA statement (Moher et al., 2009), studies
‘AND’ Boolean operator to bring together both major concepts (DT and included in the meta-analysis were assessed for quality. Quality

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assessment was completed using an adapted version of the National across psychopathology domains) associations with DT. Furthermore,
Heart, Lunch, and Blood Institute’s (NHLBI) Quality Assessment Tool for for disorder-specific associations, we meta-analysed overall associations
Observational and Cohort and Cross-Sectional Studies (https://www.nh between DT and each psychopathology domain, as well as psychopa­
lbi.nih.gov/health-topics/study-quality-assessment-tools). For criteria, thology subdomains (e.g., ‘diagnosis’ vs. ‘symptoms’). We used moder­
adaptations, and scoring, see supplemental materials. First, 20% of ator analyses to check the suitability of combining psychopathology
studies were assessed for quality independently by the first and fourth outcomes in analyses; for example, to test whether it was justifiable to
author. Discrepancies in quality ratings were discussed between these meta-analyse the overall relationship between DT and impulsive-type
authors to reach a more objective conclusion and guide assessment of psychopathology, we examined whether this relationship was moder­
the remaining studies, which was completed by the first author. ated by psychopathology domain. Finally, for moderation by sample
type, DT measurement type, age, and gender, we used the highest-level
2.5. Data extraction and coding relationship that was justifiable within each psychopathology domain.
Moderator analyses were conducted only when the number of studies
For the meta-analysis, correlation coefficients for the association per level of the moderator was n ≥ 2 for at least two levels. The complete
between DT and the relevant psychopathology measure(s) were data set and code for these analyses are available online and accessible
extracted, along with measurement details. For studies whose mea­ via: https://osf.io/9xyf4/.
surement of DT consisted of both total and subscale scores, only the
correlation coefficient based on the total score was extracted. To assist 3. Results
with moderator analyses, data were coded for sample type (clinical vs.
non-clinical vs. combined), DT measure type (self-report vs. behav­ 3.1. Systematic search results
ioural), age group, and gender. Samples were coded as “clinical” if they
comprised participants who a) had a confirmed mental health diagnosis Fig. 1 presents the PRISMA flow diagram of studies identified using
or b) were recruited from a mental health treatment facility or service. In our search strategy, which was carried out on October 1, 2020. Of the
terms of age, samples were coded as “adolescent” (mean age < 18 years), 2,561 articles found, 1,632 articles were retained following the removal
“young adult” (mean age ≥ 18 and < 30 years), or “adult” (mean age ≥ of duplicates. The vast majority of these (86.9%) did not meet criteria for
30 years). In terms of gender, samples were coded as “predominantly inclusion in the title/abstract screen. Of the 214 full-text articles
female” (percentage female ≥ 75%), “predominantly male” (percentage assessed for eligibility, 133 articles were excluded with reasons. Forty-
female < 25%), or “balanced” (percentage female ≤ 25% and < 75%). one authors were contacted regarding missing data, of which 14
(34.1% response rate) authors responded. Nine of these authors pro­
2.6. Data preparation and analysis vided additional data, while others replied stating the data was un­
available. Regarding validation screening, the degree of interrater
Prior to undertaking analyses, DT measurement information was agreement between the first and fourth author was very strong for title/
examined to determine whether higher scores indexed greater or lower abstract screening (PABAK = 0.94; Byrt et al., 1993) and strong for
levels of DT. For studies in which higher scores represented lower DT (i. full-text eligibility screening (PABAK = 0.77; Byrt et al., 1993). The
e., distress intolerance), the direction of extracted r values was reversed. fourth author initially included four full-text articles excluded by the
Furthermore, for studies reporting relevant between-group differences first author; these four articles were later excluded through mutual
in DT but no correlation coefficient, an r value was calculated based on agreement.
the available data using open-source effect size calculators (https
://doomlab.shinyapps.io/mote/; http://escal.site/). Where studies did 3.2. Study characteristics
not report either a correlation coefficient or data necessary to calculate
one, the corresponding authors were contacted via email to obtain the For a complete overview of study characteristics, see Table S1 in
data. Studies with missing data following this process were excluded supplemental materials. A total of 81 studies (N = 41,328), published
from analyses. from 1996 to 2020, were included in meta-analyses. The vast majority of
All meta-analytic results were computed using the software R (R Core studies (82.7%; n = 67) were conducted in the United States, and only
Team, 2017). The majority of studies included in these computations two studies were conducted in non-Western countries. Sample sizes
reported multiple effects (i.e., r values) from the one sample and ranged from 15 to 19,451 participants (M = 503.06, SD = 2168.78),
therefore represented clustered data. To address this clustering, we used with a mean sample age of 29.70 (SD = 11.62). Forty six studies (56.8%)
a robust variance meta-analysis with random effects using the Robumeta examined DT in relationship to PSU only, 16 studies (19.8%) in relation
package in R (v3.3.2; Fisher et al., 2017). This approach accounts for the to DEB only, and 15 studies (18.5%) in relation to BPD only. Only three
within-cluster correlation of effect sizes via robust estimation of sample studies (3.7%) examined DT in relation to more than one type of psy­
weights and standard errors, thus removing the requirement for only one chopathology (PSU and BPD: n = 2; PSU and DEB: n = 1). Fifty eight
effect to be used per study per meta-analysis and maximising the (71.6%) studies measured DT using self-report methods only, while 11
available data for analysis (Hedges et al., 2010; Tanner-Smith et al., studies (13.6%) used only behavioural measures and 12 studies (14.8%)
2016; Tanner-Smith and Tipton, 2014; Tipton, 2013). For robust vari­ used both self-report and behavioural measures. The Distress Tolerance
ance analyses, an assumed within cluster correlation of rho = 0.80 was Scale (DTS; Simons and Gaher, 2005) was the most commonly used
employed. Sensitivity analyses using different assumed rho values found self-report measure, employed by 69.1% (n = 56) of studies. Compu­
this decision had no impact on the estimates. For meta-analyses terised versions of the Paced Auditory Serial Addition Task (PASAT-C;
comprising studies that only contributed one effect size, a standard Lejuez et al., 2003) and Mirror Tracing Persistence Task (MTPT-C;
random effects meta-analysis was conducted using the metafor package Strong et al., 2003) were the most commonly used behavioural mea­
(Viechtbauer, 2010). Gignac and Szodorai’s (2016) guidelines were used sures, employed by 14.8% (n = 12) and 11.1% (n = 9) of studies,
to interpret the effect sizes of r values: Small (r = ±0.10), Medium respectively. Over half of studies (55.6%; n = 45; N = 31,347) were of
(r = ±.20) and Large (r = ±.30). Heterogeneity across studies was young adult samples, while 40.7% (n = 33; N = 9080) were in adult
examined using the I2 statistic, which ranges from 0 to 100%, where samples and 3.7% (n = 3; N = 901) in adolescent samples. On average,
high scores indicate a high degree of heterogeneity due to samples were 57.9% female and 65.8% White. University students
between-study variability rather than chance. constituted the most common sample type amongst studies (35.8%;
In line with our research aims, we examined both disorder-specific (i. n = 29), followed by community samples (25.9%; n = 21) and
e., within each psychopathology domain) and transdiagnostic (i.e., treatment-seeking samples (24.7%; n = 20).

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Fig. 1. PRISMA Flow Diagram of Systematic Search Results.

3.3. Quality assessment and drugs. We formally tested whether these differences influenced the
relationships of interest by examining substance type (‘alcohol’ vs.
See Table S2 in supplementary materials for a comprehensive over­ ‘drug’ vs. ‘combined’) as a moderator. Substance type did not moderate
view of quality ratings against the criteria in the NHLBI quality assess­ the relationship between DT and problems, F(1.15) = 12.40, p = .15, nor
ment tool. All studies were considered to have clearly outlined research the relationship between DT and SUD diagnosis, t(2) = –.80, p = .51.
questions, and all except a few studies clearly defined the sample pop­ This finding provides justification for the grouping of outcome measures
ulation. However, a common problem was a lack of information pro­ irrespective of substance type within these subdomains. As shown in
vided about the samples. Firstly, few studies commented on the rate of Table 2, DT shared a large, negative association with SUD diagnosis and
participation out of eligible persons. Secondly, no studies provided a medium, negative association with problems. Furthermore, DT shared
sample size justifications for analyses, meaning in some instances the a medium, negative association with overall PSU (SUD diagnosis and
sample sizes may have been inadequate to detect hypothesised re­ problems combined). When formally testing whether this overall rela­
lationships. Thirdly, across almost all studies it was unclear as to the tionship was moderated by PSU subdomain, we found no significant
timeframe in which participants were recruited. moderation effect, t(3.25) = 2.64, p = .071. As such, the grouping of
subdomains to characterise the relationship between DT and PSU was
supported.
3.4. Quantitative review: Meta-analysis
3.4.2. Distress tolerance and disordered eating behaviours
3.4.1. Distress tolerance and problematic substance use Psychopathology measures within the DEB domain fell into one of
Studies used a variation of measures to index PSU, with some being the following three categories: outcomes based on ED-B/P diagnosis (e.
more semantically aligned than others. Measures were found to fall in g., Bulimia Nervosa); measures of DEB frequency (e.g., the Timeline
one of two subdomains, one indexing problems associated with sub­ Follow Back method; Sobell and Sobell, 1992); and measures tapping
stance use, termed ‘problems’, and the other measuring clinical di­ symptoms of DEB in a broader sense (e.g., Bulimia subscale of the Eating
agnoses of alcohol and drug use disorders, termed ‘SUD diagnosis’. Disorder Inventory; Garner et al., 1983). We termed these categories
Furthermore, outcomes within the PSU domain varied in terms of ‘ED-B/P diagnosis’, ‘DEB frequency’, and ‘DEB symptoms’, respectively.
whether they related to just alcohol, drugs other than alcohol, or alcohol

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Table 2
Meta-Analytic Results for the Association Between Distress Tolerance and Impulsive-Type Psychopathology Domains and Subdomains.
Psychopathology Domain Subdomain N (articles) N (samples) N (associations) Total N r [95% CI] p τ2 I2
b,c
PSU 49 52 124 34,795 –.18 [–.23, –.12] <0.001 0.017 88.99
SUD diagnosis 4 4 4 471 –.41 [–.66, –.092] .028 0.032 76.01
Problems 45b,c 48 120 34,581 –.16 [–.21, –.10] <0.001 0.015 87.99
DEB 17 19 61 3,722 –.20 [–.29, –.10] <0.001 0.040 88.29
ED-B/P diagnosis 3a 3 6 515 –.28 [–.72, 0.31] .18 0.089 93.23
DEB frequency 7b 8 34 1,769 –.071 [–.22, 0.082] .30 0.021 76.88
DEB symptoms 7b 8 21 1,438 –.25 [–.39, –.094] .007 0.032 83.94
BPD 18b,c 21 44 3,827 –.27 (–.37, –.17) <0.001 0.11 95.10
BPD diagnosis 4d 4 4 462 –.051 [–.14, 0.041] .28 0.000 0.01
BPD symptoms 15b 17 40 3,365 –.31 [–.42, –.19] <0.001 0.11 95.43

Note. DEB = disordered eating behaviours. BPD = borderline personality disorder. PSU = problematic substance use. adf < 4 (underpowered and therefore unreliable).
b
Includes studies that provided separate effect sizes for clinical and non-clinical participants. cIncludes studies that provided separate effect sizes for females and males.
d
Standard meta-analysis run (no clustering; only one result per study available).

As shown in Table 2, DT was significantly associated with DEB symp­ with overall impulsive-type psychopathology, we tested whether the
toms only, and this association was depicted by a medium, negative relationship between DT and the superordinate outcome of impulsive-
correlation. Furthermore, DT shared a medium, negative association type psychopathology (PSU, DEB, and BPD combined) was moderated
with overall DEB (ED-B/P diagnosis, DEB symptoms, and DEB frequency by psychopathology domain. We found this moderation effect to be non-
combined). There was no significant moderation effect of DEB sub­ significant, F(34.7) = 1.79, p = .19. Consequently, clustering of the three
domain on the relationship between DT and DEB overall, F(3.72) = 1.28, psychopathology domains to characterise the transdiagnsotic relation­
p = .33. As such, the grouping of subdomains to characterise the rela­ ship between DT and impulsive-type psychopathology was supported.
tionship between DT and DEB was supported. Overall, DT shared a medium, negative association with impulsive-
type psychopathology, r = –.21, p < .001, 95% CI [–.25, –.16].
3.4.3. Distress tolerance and borderline personality disorder
Within the BPD domain, measures were found to index either clinical 3.4.5. Moderator analyses
diagnosis of BPD or the full continuum of BPD symptomatology. We As shown in Table 2, the I2 for most meta-analyses were high, which
termed these categories ‘BPD diagnosis’ and ‘BPD symptoms’ to repre­ suggests a high degree of variation across studies due to study hetero­
sent BPD subdomains. As shown in Table 2, DT was significantly asso­ geneity rather than chance (Higgins and Thompson, 2002). Therefore,
ciated with BPD symptoms only, and this association was depicted by a we examined whether the transdiagnostic relationship and
large, negative association. Furthermore, DT shared a medium, negative disorder-specific relationships reported above were moderated by DT
association with overall BPD (BPD diagnosis and BPD symptoms com­ measurement type (self-report vs. behavioural), sample type (clinical vs.
bined). There was no moderation effect of BPD subdomain on the rela­ non-clinical vs. combined), age group (adolescent vs. young adult vs.
tionship between DT and BPD overall, t(4.44)= –.20, p = .086. adult), and gender distribution (predominantly female vs. predomi­
Consequently, the grouping of subdomains to characterise the rela­ nantly male vs. balanced). Results of overall moderation effects are
tionship between DT and BPD symptomatology was supported. displayed in Table 3.

3.4.4. Distress tolerance and impulsive-type psychopathology 3.4.5.1. Measurement type. As shown in Table 3, there was a significant
To examine whether DT demonstrated a transdiagnostic relationship moderation effect of DT measurement type on the relationship between

Table 3
Results of Moderator Analyses.
Psychopathology Outcome Moderator Moderator Levels F(df) P τ2 I2

PSU
Measurement type (SR, B) 3.83(12.3) .073 0.018 88.98
Sample type (C, NC, CO) 31.70(4.63) .002 0.016 87.56
Age (ADO, YA, ADU) 8.12(5.55) .023 0.023 88.01
Gender (PF, PM, BA) 1.62(11.90) .24 0.026 89.19
DEB
Measurement type (SR, B) 0.41(4.04) .56 0.041 88.39
Sample type (C, NC, CO) 0.63(2.25) .61 0.045 89.26
Ageb (YA, ADU) 0.29(13.00) .60 0.042 88.95
Genderc (PF, BA) 0.89(14.30) .36 0.041 88.15
BPD
Measurement type (SR, B) 11.10(13.30) .005 0.080 93.29
Sample type (C, NC, CO) 1.33(2.30) .41 0.095 94.22
Ageb (YA, ADU) 1.60(18.60) .22 0.10 94.53
Genderc (PF, BA) 0.00(14.40) .99 0.12 95.39
Impulsive-type psychopathologya
Measurement type (SR, B) 9.20(28.30) .005 0.036 92.83
Sample type (C, NC, CO) 1.38(16.00) .28 0.037 92.93
Age (ADO, YA, ADU) 10.60(7.22) .007 0.042 92.30
Gender (PF, PF, BA) 0.48(29.70) .62 0.049 92.87

Note. PSU = problematic substance use. DEB = disordered eating behaviours. BPD = borderline personality disorder. a = Superordinate outcome combining PSU, DEB,
and BPD. SR = self-report. B = behavioural. C = Clinical. NC = non-clinical. CO = combined. ADO = adolescent. YA = young adult. ADU = adult. PF = predominantly
female. PM = predominantly male. BA = balanced. b = Insufficient n (samples) at the ‘adolescent’ level of the moderator. c = Insufficient n (samples) at ‘predominantly
male’ level of the moderator. Significant moderation effects are highlighted in bold.

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DT and BPD as well as the transdiagnostic relationship between DT and problems, SUD diagnosis, DEB symptoms, and BPD symptoms, as DT was
impulsive-type psychopathology. Conversely, DT measurement type did not significantly associated with diagnoses of EDs-B/P or BPD, nor fre­
not moderate the relationships between DT and PSU nor DEB. The quency of DEB. Crucially, when combining PSU, DEB, and BPD symp­
magnitude of the negative association between DT and BPD was greater tomatology into a superordinate outcome of impulsive-type
for self-report measures (r = –.36, 95% CI [− 0.46, − 0.24]) than psychopathology, we found that its relationship with DT did not differ
behavioural measures (r = –.079, 95% CI [–.13, –.005]), t across the three psychopathology domains, which is consistent with a
(13.28) = 3.33, p = .005. Similarly, the magnitude of the negative as­ transdiagnostic conceptualisation of this relationship. However, evi­
sociation between DT and impulsive-type psychopathology was greater dence was found for DT measurement type, sample type, and age group
for self-report measures (r = –.23, 95% CI [–.28, –.18]) than behavioural moderating some of these relationships, which we discuss in further
measures (r = –.074, 95% CI [–.13, –.017]), t(28.30) = 3.03, p = .005. detail below.
The present finding that DT was negatively associated with PSU, DEB
3.4.5.2. Sample type. There was a significant moderation effect of symptoms, and BPD symptomatology is consistent with theoretical as­
sample type on the relationship between DT and PSU. Sample type did sumptions regarding the role of DT in the aetiology of impulsive-type
not significantly moderate the relationships between DT and DEB, BPD, psychopathology. Research demonstrates that behavioural symptoms of
nor impulsive-type psychopathology. Pair-wise comparisons revealed SUDs, EDs-B/P, and BPD commonly occur during states of affective
the magnitude of the negative association between DT and PSU was distress (Lavender et al., 2016; McHugh and Kneeland, 2019; Santangelo
significantly greater for combined samples (r = –.52, 95% CI [–.65, et al., 2014). Furthermore, experiences of significant environmental
–.36]) when compared with both clinical samples (r = –.20, 95% CI stress, such as childhood trauma or neglect, are a shared risk factor for
[–.35, –.050]), t(2.87) = 4.44, p = .023, and non-clinical samples the development of these disorders (Cotter et al., 2014; Edalati and
(r = –.14, 95% CI [–.20, –.048]), t(2.20) = 8.71, p = .010. However, Krank, 2016; Molendijk et al., 2017). However, not all individuals
there was no significant difference in the magnitude of this association exposed to such experiences engage in behaviours characteristic of
between clinical samples and non-clinical samples, t(15.30) = 0.80, impulsive-type psychopathology; It has been theorised that low DT is
p = .43. Given this latter non-significant finding and the small number of one mechanism increasing an individual’s vulnerability towards dysre­
studies with combined samples (n = 3) within the PSU domain, we gulated behaviours that function to help the individual alleviate or
caution drawing inferences from this moderation effect. escape from emotional discomfort, including substance use,
binge-eating and purging, and behaviours commonly observed in BPD
3.4.5.3. Age. Sample age group significantly moderated the relation­ (e.g., deliberate self-harm; Leyro et al., 2010). However, the medium
ships between DT and PSU as well as the transdiagnostic relationship effect sizes for the association between DT and psychopathology found
between DT and impulsive-type psychopathology. There was no signif­ in the present study suggest that such processes contribute only partially
icant moderation effect of age group on the relationships between DT to the overall pathogenesis of these disorders, which highlights the
and DEB nor BPD. Pair-wise comparisons for the relationship between importance of considering the interplay amongst low DT and other
DT and PSU revealed a significant difference in the association when mechanisms of affective vulnerability.
comparing adult samples (r = –.23, 95% CI [–.31, –.15]) and adolescent In contrast, the finding that DT was not significantly associated with
samples (r = 0.041, 95% CI [− 0.18, 0.26]), t(2.68) = 4.32, p = .029, diagnoses of ED-B/P or BPD, nor frequency of DEB, is inconsistent with
with the association being non-significant for adolescent samples. theory regarding the role of DT in these disorders, as well as previous
Young-adult samples (r = –.16, 95% CI [–.24, –.076]) did not differ studies demonstrating lower levels of DT in individuals with these dis­
significantly from neither adolescent samples, t(2.61) = 3.15, p = .062, orders compared to healthy controls (Gratz et al., 2006; Mountford
nor adult samples, t(44.96) = –1.33, p = .19. For the relationship be­ et al., 2007). Regarding DEB frequency, the present findings suggest DT
tween DT and impulsive-type psychopathology, pair-wise comparisons may be most relevant to the cognitive and affective processes sur­
revealed significant differences in the associations when comparing rounding DEB. For example, low DT may underpin occurrences of DEB
adolescent samples (r = 0.054, 95% CI [–.15, 0.25] with both adult that function to alleviate or escape distress rather than when such
samples (r = –.23, 95% CI [–.29, –.16]), t(3.15) = − 4.68, p = .017, and behaviour is undertaken with the expectation of pleasure (De Young
young adult samples (r = –.21, 95% CI [–.27, –.14]), t(3.07) = –4.40, et al., 2014). However, in line with this theory, it would be reasonable to
p = .021, with the association being non-significant for adolescent expect lower levels of DT amongst individuals with clinical levels of DEB
samples. There was no significant difference in the strength of the as­ and BPD symptomatology, who would presumably demonstrate the
sociation when comparing adult and young-adult samples, t most profound cognitive and affective symptomatology surrounding
(77.64) = 0.31, p = .76. behavioural dysregulation. The lack of association between DT and
these outcomes found in the present study may be explained by choice of
3.4.5.4. Gender. No significant moderation effects were found for DT measurement amongst the small number of studies examining these
gender distribution. subdomains (ED-B/P diagnosis: N = 2; BPD diagnosis: N = 4). Specif­
ically, a larger proportion of studies used behavioural measures of DT or
4. Discussion self-report measures with greater emphasis on behavioural avoidance of
negative affect (e.g., Corstorphine et al., 2007), which may not fully
To our knowledge, the present study was the first to meta-analyse the capture the DT construct (Leyro et al., 2010; Simons et al., 2005).
relationships between DT and PSU, DEB, and BPD symptomatology
simultaneously, in an attempt to clarify the transdiagnostic utility of DT 4.1. The prevailing issue of distress tolerance measurement heterogeneity
across impulsive-type psychopathology. A systematic search was con­
ducted to collate studies examining the association between DT and Consistent with the above line of thinking, we found DT measure­
PSU, DEB, or BPD symptomatology in either clinical or non-clinical ment type was a significant moderator for the relationship between DT
populations. Meta-analysis of 81 studies, comprising 41,328 partici­ and BPD symptomatology as well as the transdiagnostic relationship
pants, revealed DT shared medium, negative associations with each between DT and impulsive-type psychopathology. Specifically, the re­
psychopathology domain, as well as impulsive-type psychopathology lationships between DT and these outcomes were stronger for self-report
overall (PSU, DEB, and BPD symptomatology combined). However, measures than behavioural measures of DT. This finding is consistent
when further specifying outcomes within each psychopathology with previous research demonstrating a lack of convergent validity be­
domain, significant associations were confined to substance use tween self-report and behavioural measures of DT (Kiselica et al., 2015;
McHugh et al., 2011), and studies showing self-reported DT is more

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strongly related to bulimic symptoms (Anestis et al., 2012b) and 4.3. The moderating effect of age and sample type
impulsivity (Kiselica et al., 2015) than behavioural DT. It is important to
consider the differing operationalisations of DT tapped by self-report In addition to the moderating effect of DT measurement type, we
and behavioural measures that are likely to explain these results found evidence for age group and sample type moderating some of the
(McHugh et al., 2011). In particular, behavioural measures of DT, such relationships examined. When considering both PSU and impulsive-type
as the PASAT-C and MTPT-C, index DT based on one’s persistence on a psychopathology overall as outcomes, there was a negative association
task relating to a specific goal or reward, while self-report measures with DT in adult samples, while the association in adolescent samples
index an individual’s perception of their ability to tolerate distress was non-significant. An important consideration in interpreting this
generally (Glassman et al., 2016; McHugh et al., 2011). The current finding is the reduced opportunity for adolescents to engage in alcohol
findings indicate that, in the case of BPD and impulsive-type use given legislative limitations as well as the possibility of less
psychopathology generally, the latter operationalisation of DT may be entrenched problems. Consequently, low DT in adolescence may be
more relevant to psychopathology risk and severity. Whereas, for PSU more likely to manifest in other maladaptive behaviours, perhaps
and DEB, both operationalisations of DT appear to carry equal weight characteristic of developmental externalising psychopathology (Cum­
in terms of these outcomes. Given these differing operationalisations mings et al., 2013). However, in light of the high prevalence of binge
are likely to demand distinct approaches in terms of intervention, drinking, one aspect of problematic alcohol use, amongst adolescents
gaining clarity around the unique roles of these two processes in (Aiken et al., 2018), it is also possible that the mechanisms for PSU vary
psychopathology is an important area for future research. across development. For example, one study included in the present
meta-analysis found that negative urgency, but not DT, mediated the
relationship between anxiety symptoms and PSU in a sample of ado­
4.2. The transdiagnostic utility of distress tolerance lescents (Wolitzky-Taylor et al., 2016). Therefore, future research is
needed to clarify the potentially changing role of DT in PSU across
Despite widespread conceptualisation of DT as a transdiagnostic development, as suggested by the present findings.
construct (Jacquart et al., 2019; Lebeaut et al., 2021; Ritschel et al., In addition to this moderation effect, specifically within the PSU
2015; Wright et al., 2020), the present findings reveal that very few domain, the association was stronger for combined samples when
studies have examined the relationship between DT and impulsive-type compared to both clinical and non-clinical samples, with the association
psychopathology across different psychopathology domains. Instead, in clinical samples found to be non-significant. As previously mentioned,
studies have predominantly sought to investigate the role of DT in the we caution inferences being drawn about the particular relevance of DT
aetiology of specific disorders, thus limiting clarification of the trans­ in combined samples due to the relatively small number of studies in this
diagnostic utility of DT; a limitation of the literature identified over a subcategory, which increases the likelihood of sampling error. However,
decade ago (Leyro et al., 2010). In collating three predominantly sepa­ the non-significant association in clinical samples was particularly sur­
rate literatures, we were able to employ moderation analyses to examine prising given recent increases in interventions designed to target low DT,
whether the association differed across psychopathology domains. The either directly or indirectly (e.g., via mindfulness skills training), in
present study was the first to demonstrate that the magnitude of the individuals with SUD (e.g., see Black and Amaro, 2019; Russell et al.,
negative association between DT and impulsive-type psychopathology 2019; Vujanovic et al., 2018), and findings indicating improvements in
did not differ significantly across the three psychopathology domains. DT in response to SUD treatment (Banducci et al., 2017; Black and
This finding is consistent with transdiagnostic explanations of the role of Amaro, 2019). Therefore, further research should aim to clarify the
DT in the aetiology and maintenance of impulsive-type psychopathol­ circumstances under which a relationship between DT and SUD severity
ogy. For example, low DT may interact with other underlying vulnera­ exists, as such clarification is needed to underpin existing and future DT
bility factors, such as impulsivity (Johnson et al., 2013) or emotion interventions.
dysregulation (Sloan et al., 2019), in increasing vulnerability towards
impulsive-type psychopathology, with particular attention having 4.4. Limitations and future research directions
recently been paid to the potential conjoint roles of low DT and high
negative urgency in predicting problematic alcohol use (Yang et al., The findings of the current study are underpinned by several
2019; Zapolski et al., 2019). It is also possible that low DT interacts with strengths, including the large number of studies included in primary
genetic vulnerabilities underpinning impulsive-type psychology, with meta-analyses, the inclusion of both clinical and non-clinical samples,
research demonstrating a heritage component across SUDs, EDs-B/P, and using a clear definition of DT to guide the systematic search.
and BPD (Sansone and Levitt, 2005; Trull et al., 2018). Additionally, low However, there are also some important limitations worth noting. First,
DT may function as a mediating factor in the relationship between other most samples across studies were imbalanced in terms of ethnicity, with
shared, more distal risk factors, such as childhood trauma (McLaughlin findings being more representative of individuals identifying as White or
et al., 2020). Caucasian. Further, only two studies were conducted outside of Western
However, this finding should also be interpreted in light of the me­ countries. Given there is some evidence for DT functioning differently in
dium association between low DT and impulsive-type psychopathology non-White individuals (Daughters et al., 2009; McIntosh et al., 2021),
found in the present study, suggesting that such transdiagnostic pro­ these study characteristics strongly limit the generalisability of these
cesses are only partially responsible for the impulsivity underpinning findings to other ethnicities. Second, a relatively large number of studies
SUDs, EDs-B/P, and BPD. Accordingly, the current findings highlight the were excluded based on missing data and lack of author response. Given
importance of continuing to consider how such transdiagnostic expla­ publication bias against null findings, it is possible that authors chose
nations may interact with disorder-specific processes, such as body not to report such data and, consequently, the pooled coefficients may
dissatisfaction in the case of EDs-B/P (Racine et al., 2017; Racine and be over-estimates.
Martine, 2016). Further research is needed to understand the Third, despite the relevance of adolescence to risk of impulsive-type
disorder-specific processes that may interact with low DT to result in psychopathology, very few studies (n = 3; N = 901) in the present meta-
specific manifestations of impulsive-type psychopathology. Therefore, analysis were of adolescent samples. Adolescence constitutes a vulner­
while the current findings lend support to the recent development of able period of development, which carries increased risk of engagement
transdiagnostic interventions designed to target low DT for individuals in impulsive behaviours that may depict early manifestations of
with impulsive-type psychopathology (e.g., Hall et al., 2018, 2021; impulsive-type psychopathology (Beauchaine et al., 2017).
Ritschel et al., 2015), they also suggest that such interventions may need Furthermore, with the average ages of onset for SUDs, EDs-B/P, and
to be combined with disorder-specific interventions. BPD occurring in early adulthood (Kessler et al., 2007), adolescence

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represents a critical developmental period for early intervention. It has type and age, highlighting important nuances in this relationship that
been argued that such early intervention should target the development may need to be integrated into future theoretical accounts of DT and
of emotion regulation skills, including DT, to assist in healthy DT-targeted intervention. The present research also demonstrates the
psychosocial development (De France and Hollenstein, 2019). For need for future research to increase understanding surrounding the in­
these reasons, it is imperative that future research is undertaken to fluences of ethnicity, developmental stage, and different DT dimensions
increase understanding of the role that DT may play in the on the relationship between DT and impulsive-type psychopathology.
developmental sequalae of impulsive-type psychopathology. The current findings provide important groundwork which may assist
Fourth, the current findings do not shed light on the transdiagnostic in the progression of novel and existing interventions targeting DT for
relevance of DT beyond our three chosen categories of psychopathology. impulsive-type psychopathology.
Our study utilised the approach of selecting a cluster of disorders whose
overlapping clinical features, aetiology, and comorbidity highlight un­ Contributors
derlying transdiagnostic mechanisms, as has been done recently in
relation to non-suicidal self-injury and risky drinking (Greene et al., Author S. M. conceptualised the research questions, developed the
2020). However, it is important to note that the transdiagnostic utility of study protocol, conducted the systematic search, completed title and
DT is likely to extend beyond these categories of psychopathology, with abstract screening, extracted all data, conducted statistical analyses, and
a role for low DT having been implicated across anxiety disorders wrote the first and subsequent drafts of the manuscript. Author G. Y.
(Laposa et al., 2015), depressive disorders (Lass and Winer, 2020), reviewed the study protocol, assisted with statistical analyses, and
obsessive-compulsive and related disorders (Grisham et al., 2018; conceptualised the structure of the methods, results, and discussion
Laposa et al., 2015), and post-traumatic stress disorder (Akbari et al., section of the manuscript. Author V. M. contributed to early con­
2021). Low DT may be best conceptualised as a transdiagnostic ceptualisation of research questions and contributed to the introduction
vulnerability factor contributing to maladaptive coping behaviours that and discussion sections of the manuscript. Author L. G. completed the
are either internalising (e.g., rumination; Lass et al., 2020) or external­ validation for eligibility screening and quality assessment and contrib­
ising (e.g., substance use; Farris et al., 2016). Examining the degree to uted to all parts of the manuscript. Author K. H. contributed to research
which the transdiagnostic relationship between DT and psychopathol­ question conceptualisation, reviewed the study protocol, and contrib­
ogy loads onto these broader conceptualisations of psychology, such as uted to all parts of the manuscript. All authors have approved the final
through meta structural equation modelling, is an important area for manuscript.
future research.
Fifth, despite growing consensus that DT is best represented as Funding
multidimensional (Bebane et al., 2015; Bernstein et al., 2009; Glassman
et al., 2016; Rogers et al., 2020), the current findings do not shed light This research did not receive any specific grant from funding
on relationships between different dimensions of DT and impulsive-type agencies in the public, commercial, or not-for-profit sectors.
psychopathology. Studies that have demonstrated differential
relationships between PSU and different dimensions of the DTS—the
most frequently used DT measure in the current study—suggest Declaration of Competing Interest
consideration of the potential varied roles of different DT dimensions
is warranted (e.g., Greenberg et al., 2016; Khan et al., 2018). None.
However, findings of a more recent investigation did not support the
incremental utility of specific DT dimensions over the general DT Acknowledgements
factor (i.e., DTS Total score; Rogers et al., 2020). Furthermore, there is
evidence to suggest that a general DT factor may be better The authors would like to acknowledge and thank Dr Jason Bos for
conceptualised as encompassing a broader range of lower-order di­ his mentorship and support in the writing of this manuscript.
mensions, including constructs depicting tolerance towards specific
emotional states (e.g., frustration intolerance; Bebane et al., 2015). The Supplementary materials
current findings underscore that interchangeable use of DT measures
comprised of different dimensions remains a significant limitation of the Supplementary material associated with this article can be found, in
literature, precluding comparability amongst findings. As such, clari­ the online version, at doi:10.1016/j.jad.2021.12.126.
fying the nomological network of the DT construct and the differential
relations of DT dimensions with impulsive-type psychopathology re­ References*
mains an important area for future investigation.
Aiken, A., Clare, P.J., Wadolowski, M., Hutchinson, D., Najman, J.M., Slade, T.,
Bruno, R., McBride, N., Kypri, K., Mattick, R.P., 2018. Age of alcohol initiation and
5. Conclusion
progression to binge drinking in adolescence: a prospective cohort Study.
Alcoholism: Clin. Exp. Res. 42 (1), 100–110. https://doi.org/10.1111/acer.13525.
The present study was the first to synthesise and quantitatively Akbari, M., Hosseini, Z.S., Seydavi, M., Zegel, M., Zvolensky, M.J., Vujanovic, A.A.,
2021. Distress tolerance and posttraumatic stress disorder: a systematic review and
summarise existing research on the association between self-report and
meta-analysis. Cogn. Behav. Ther. 1–30. https://doi.org/10.1080/
behavioural measures of DT and sub-clinical and clinical levels of 16506073.2021.1942541.
impulsive-type psychopathology (PSU, DEB, and BPD symptomatology) *Anestis, M.D., Lavender, J.M., Marshall-Berenz, E.C., Gratz, K.L., Tull, M.T., Joiner, T.E,
across all sample types. Overall, DT shared a significant, medium, 2012b. Evaluating distress tolerance measures: interrelations and associations with
impulsive behaviors. Cognit. Ther. Res. 36 (6), 593–602. https://doi.org/10.1007/
negative association with each of PSU, DEB, and BPD s10608-011-9377-8.
symptomatology; however, this association was confined to specific *Anestis, M.D., Selby, E.A., Fink, E.L., Joiner, T.E., 2007. The multifaceted role of distress
subdomains (i.e., psychopathology measurement types) within each tolerance in dysregulated eating behaviors. Int. J. Eat. Disord. 40 (8), 718–726.
https://doi.org/10.1002/eat.20471.
category. The present study was the first to indicate that the Bahji, A., Mazhar, M.N., Hudson, C.C., Nadkarni, P., MacNeil, B.A., Hawken, E., 2019.
magnitude of the negative association between DT and impulsive-type Prevalence of substance use disorder comorbidity among individuals with eating
psychopathology does not differ significantly across these three
psychopathology categories. Thus, the present findings lend crucial
support to transdiagnostic conceptualisation of this relationship. *
References marked with an asterisk indicate studies included in the meta-
However, evidence was found for moderation by DT measurement analysis.

500
S. Mattingley et al. Journal of Affective Disorders 300 (2022) 492–504

disorders: a systematic review and meta-analysis. Psychiatry Res. 273, 58–66. Fisher, Z., Tipton, E., Zhipeng, H., 2017. Package “robumeta.” https://cran.r-project.
https://doi.org/10.1016/j.psychres.2019.01.007. org/web/packages/robumeta/robumeta.pdf.
Banducci, A.N., Connolly, K.M., Vujanovic, A.A., Alvarez, J., Bonn-Miller, M.O., 2017. Garner, D.M., Olmstead, M.P., Polivy, J., 1983. Development and validation of a
The impact of changes in distress tolerance on PTSD symptom severity post- multidimensional Eating Disorder Inventory for anorexia and bulimia. Int. J. Eat.
treatment among veterans in residential trauma treatment. J. Anxiety Disord. 47, Disord. 2 (2), 15–34. https://doi.org/10.1002/1098-108X(198321)2:2<15::
99–105. https://doi.org/10.1016/j.janxdis.2017.01.004. AID-EAT2260020203>3.0.CO;2-6.
Beauchaine, T.P., Zisner, A.R., Sauder, C.L., 2017. Trait impulsivity and the externalizing Gignac, G.E., Szodorai, E.T., 2016. Effect size guidelines for individual differences
spectrum. Annu. Rev. Clin. Psychol. 13, 343–368. https://doi.org/10.1146/annurev- researchers. Pers. Individ. Dif. 102, 74–78. https://doi.org/10.1016/j.
clinpsy-021815-093253. paid.2016.06.069.
Bebane, S., Flowe, H.D., Maltby, J., 2015. Re-refining the measurement of distress Gillan, C.M., Seow, T.X.F., 2020. Carving out new transdiagnostic dimensions for
intolerance. Pers. Individ. Dif. 85, 159–164. https://doi.org/10.1016/j. research in mental health. Biol. Psychiatry: Cognit. Neurosci. Neuroimaging 5 (10),
paid.2015.05.005. 932–934. https://doi.org/10.1016/j.bpsc.2020.04.013.
Bernstein, A., Zvolensky, M.J., Vujanovic, A.A., Moos, R., 2009. Integrating anxiety Glassman, L.H., Martin, L.M., Bradley, L.E., Ibrahim, A., Goldstein, S.P., Forman, E.M.,
sensitivity, distress tolerance, and discomfort intolerance: a hierarchical model of Herbert, J.D., 2016. A brief report on the assessment of distress tolerance: are we
affect sensitivity and tolerance. Behav. Ther. 40 (3), 291–301. https://doi.org/ measuring the same construct? J. Rational Emotive Cognit. Behav. Therapy 34 (2),
10.1016/j.beth.2008.08.001. 87–99. https://doi.org/10.1007/s10942-015-0224-9.
Black, D.S., Amaro, H., 2019. Moment-by-Moment in Women’s Recovery (MMWR): Greene, D., Boyes, M., Hasking, P., 2020. The associations between alexithymia and both
mindfulness-based intervention effects on residential substance use disorder non-suicidal selfinjury and risky drinking: a systematic review and meta-analysis.
treatment retention in a randomized controlled trial. Behav. Res. Ther. 120, 103437. J. Affect. Disord. 260, 140–166. https://doi.org/10.1016/j.jad.2019.08.088.
https://10.1016/j.brat.2019.103437. *Gorka, S.M., Ali, B., Daughters, S.B, 2012. The role of distress tolerance in the
Bornovalova, M.A., Gratz, K.L., Daughters, S.B., Hunt, E.D., Lejuez, C.W., 2012. Initial relationship between depressive symptoms and problematic alcohol use. Psychol.
RCT of a distress tolerance treatment for individuals with substance use disorders. Addict. Behav. 26 (3), 621–626. https://doi.org/10.1037/a0026386.
Drug Alcohol Depend 122 (1-2), 70–76. https://doi.org/10.1016/j. *Gratz, K.L., Rosenthal, M.Z., Tull, M.T., Lejuez, C.W., Gunderson, J.G, 2006. An
drugalcdep.2011.09.012. experimental investigation of emotion dysregulation in borderline personality
*Buckheit, K.A., De Vita, M., Maisto, S.A, 2019. A multimethod investigation of distress disorder. J. Abnorm. Psychol. 115 (4), 850–855. https://doi.org/10.1037/0021-
tolerance and problematic alcohol use. Exp. Clin. Psychopharmacol. 28 (2), 843X.115.4.850.
137–142. https://doi.org/10.1037/pha0000307. *Greenberg, L.P., Martindale, S.L., Fils-aimé, L.R, 2016. Distress tolerance and
*Buckner, J.D., Jeffries, E.R., Terlecki, M.A., Ecker, A.H, 2016. Distress tolerance among impulsivity are associated with drug and alcohol use consequences in an online
students referred for treatment following violation of campus cannabis use policy: community sample. J. Cognit. Psychotherapy: Int. Q. 30 (1), 50–60. https://doi.org/
relations to use, problems, and motivation. Behav. Modif. 40 (5), 663–677. https:// 10.1891/0889-8391.30.1.50.
doi.org/10.1177/0145445515610315. Grisham, J.R., Roberts, L., Cerea, S., Isemann, S., Svehla, J., Norberg, M.M., 2018. The
*Bujarski, S.J., Norberg, M.M., Copeland, J, 2012. The association between distress role of distress tolerance, anxiety sensitivity, and intolerance of uncertainty in
tolerance and cannabis use-related problems: the mediating and moderating roles of predicting hoarding symptoms in a clinical sample. Psychiatry Res. 267, 94–101.
coping motives and gender. Addict. Behav. 37 (10), 1181–1184. https://doi.org/ https://doi.org/10.1016/j.psychres.2018.05.084.
10.1016/j.addbeh.2012.05.014. Hall, K., Simpson, A., O’Donnell, R., Sloan, E., Staiger, P.K., Morton, J., Ryan, D.,
Byrt, T., Bishop, J., Carlin, J.B., 1993. Bias, prevalence and kappa. J. Clin. Epidemiol. 46 Nunn, B., Best, D., Lubman, D.I., 2018. Emotional dysregulation as a target in the
(5), 423–429. https://doi.org/10.1016/0895-4356(93)90018-V. treatment of co-existing substance use and borderline personality disorders: a pilot
Cavicchioli, M., Rugi, C., Maffei, C., 2015. Inability to withstand present-moment study. Clin. Psychol. 22 (2), 112–125. https://doi.org/10.1111/cp.12162.
experiences in borderline personality disorder: a meta-analytic review. Clinical Hall, K., Youssef, G., Simpson, A., Sloan, E., Graeme, L., Perry, N., Moulding, R., Baker, A.
Neuropsychiatry 12 (4), 101–110. https://doaj.org/article/9a5a2e28178f4e31a L., Beck, A.K., Staiger, P.K., Noel, X., 2021. An emotion regulation and impulse
37eba533364bdc5. control (ERIC) intervention for vulnerable young people : a multi-sectoral pilot
*Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., Meyer, C, 2007. Distress study. Front. Psychol. 12, 1–13. https://doi.org/10.3389/fpsyg.2021.554100.
tolerance in the eating disorders. Eat. Behav. 8 (1), 91–97. https://doi.org/10.1016/ Hedges, L.V., Tipton, E., Johnson, M.C., 2010. Robust variance estimation in meta-
j.eatbeh.2006.02.003. regression with dependent effect size estimates. Res. Synth. Methods 1 (1), 39–65.
Cotter, J., Kaess, M., Yung, A.R., 2014. Childhood trauma and functional disability in https://doi.org/10.1002/jrsm.5.
psychosis, bipolar disorder and borderline personality disorder: a review of the Higgins, J.P.T., Thompson, S.G., 2002. Quantifying heterogeneity in a meta-analysis.
literature. Ir. J. Psychol. Med. 32 (1), 21–30. https://doi.org/10.1017/ipm.2014.74. Stat. Med. 21 (11), 1539–1558. https://doi.org/10.1002/sim.1186.
Cummings, J.R., Bornovalova, M.A., Ojanen, T., Hunt, E., MacPherson, L., Lejuez, C., *Holzhauer, C.G., Wemm, S., Wulfert, E, 2017. Distress tolerance and physiological
2013. Time doesn’t change everything: the longitudinal course of distress tolerance reactivity to stress predict women’s problematic alcohol use. Exp. Clin.
and its relationship with externalizing and internalizing symptoms during early Psychopharmacol. 25 (3), 156–165. https://doi.org/10.1037/pha0000116.
adolescence. J. Abnorm. Child Psychol. 41 (5), 735–748. https://doi.org/10.1007/ Jacquart, J., Dutcher, C.D., Freeman, S.Z., Stein, A.T., Dinh, M., Carl, E., Smits, J.A.J.,
s10802-012-9704-x. 2019. The effects of exercise on transdiagnostic treatment targets: a meta-analytic
Daughters, S.B., Gorka, S.M., Rutherford, H.J.V., Mayes, L.C., 2014. Maternal and review. Behav. Res. Ther. 115, 19–37. https://doi.org/10.1016/j.brat.2018.11.007.
adolescent distress tolerance: the moderating role of gender. Emotion 14 (2), Johnson, S.L., Carver, C.S., Joormann, J., 2013. Impulsive responses to emotion as a
416–424. https://doi.org/10.1037/a0034991. transdiagnostic vulnerability to internalizing and externalizing symptoms. J. Affect.
Daughters, S.B., Reynolds, E.K., MacPherson, L., Kahler, C.W., Danielson, C.K., Disord. 150 (3), 872–878. https://doi.org/10.1016/j.jad.2013.05.004.
Zvolensky, M., Lejuez, C.W., 2009. Distress tolerance and early adolescent Juarascio, A., Manasse, S., Clark, K.E., Schaumberg, K., Kerrigan, S., Goldstein, S.P.,
externalizing and internalizing symptoms: the moderating role of gender and Evans, B.C., Wyckoff, E., Murray, H.B., Felonis, C.R., Forman, E., 2020.
ethnicity. Behav. Res. Ther. 47 (3), 198–205. https://doi.org/10.1016/j. Understanding the overlap and differences in terms describing patterns of
brat.2008.12.001. maladaptive avoidance and intolerance of negative emotional states. Pers. Individ.
De France, K., Hollenstein, T., 2019. Emotion regulation and relations to well-being Dif. 158 https://doi.org/10.1016/j.paid.2020.109859. Article 109859.
across the lifespan. Dev. Psychol. 55 (8), 1768–1774. https://doi.org/10.1037/ Juarascio, A.S., Manasse, S.M., Schumacher, L., Espel, H., Forman, E.M., 2017.
dev0000744. Developing an acceptance-based behavioral treatment for binge eating disorder:
De Young, K.P., Zander, M., Anderson, D.A., 2014. Beliefs about the emotional rationale and challenges. Cogn. Behav. Pract. 24 (1), 1–13. https://doi.org/10.1016/
consequences of eating and binge eating frequency. Eat. Behav. 15 (1), 31–36. j.cbpra.2015.12.005.
https://doi.org/10.1016/j.eatbeh.2013.10.012. *Kamody, R.C., Thurston, I.B., Burton, E.T, 2020. Acceptance-based skill acquisition and
Eaton, N.R., Rodriguez-Seijas, C., Carragher, N., Krueger, R.F., 2015. Transdiagnostic cognitive reappraisal in a culturally responsive treatment for binge eating in
factors of psychopathology and substance use disorders: a review. Soc. Psychiatry adolescence. Eat Disord. 28 (2), 184–201. https://doi.org/10.1080/
Psychiatr. Epidemiol. 50 (2), 171–182. https://doi.org/10.1007/s00127-014-1001- 10640266.2020.1731055.
2. *Kelly, N.R., Cotter, E.W., Mazzeo, S.E, 2014. Examining the role of distress tolerance
Edalati, H., Krank, M.D., 2016. Childhood maltreatment and development of substance and negative urgency in binge eating behavior among women. Eat. Behav. 15 (3),
use disorders: a review and a model of cognitive pathways. Trauma Violence Abuse 483–489. https://doi.org/10.1016/j.eatbeh.2014.06.012.
17 (5), 454–467. https://doi.org/10.1177/1524838015584370. Kessler, R.C., Amminger, G.P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., Üstün, T.B., 2007.
*Eichen, D.M., Chen, E., Boutelle, K.N., McCloskey, M.S, 2017. Behavioral evidence of Age of onset of mental disorders: a review of recent literature. Curr. Opin. Psychiatry
emotion dysregulation in binge eaters. Appetite 111, 1–6. https://doi.org/10.1016/ 20 (4), 359–364. https://doi.org/10.1097/YCO.0b013e32816ebc8c.
j.appet.2016.12.021. *Khan, A.J., Pedrelli, P., Shapero, B.G., Fisher, L., Nyer, M., Farabaugh, A.I.,
Fairburn, C.G., Cooper, Z., Shafran, R., 2003. Cognitive behaviour therapy for eating MacPherson, L, 2018. The association between distress tolerance and alcohol related
disorders: a “transdiagnostic” theory and treatment. Behav. Res. Ther. 41 (5), problems: the pathway of drinking to cope. Subst. Use Misuse 53 (13), 2199–2209.
509–528. https://doi.org/10.1016/S0005-7967(02)00088-8. https://doi.org/10.1080/10826084.2018.1464027.
*Farris, S.G., Metrik, J., Bonn-Miller, M.O., Kahler, C.W., Zvolensky, M.J, 2016. Anxiety Khosravi, M., 2020. Eating disorders among patients with borderline personality
sensitivity and distress intolerance as predictors of cannabis dependence symptoms, disorder: understanding the prevalence and psychopathology. J. Eat. Disord. 8 (1),
problems, and craving: the mediating role of coping motives. J. Stud. Alcohol Drugs 1–9. https://doi.org/10.1186/s40337-020-00314-3.
77 (6), 889–897. https://doi.org/10.15288/jsad.2016.77.889. Kim, H.S., Hodgins, D.C., 2018. Component model of addiction treatment: a pragmatic
Fischer, S., Wonderlich, J., Breithaupt, L., Byrne, C., Engel, S., 2018. Negative urgency transdiagnostic treatment model of behavioral and substance addictions. Front.
and expectancies increase vulnerability to binge eating in bulimia nervosa. Eat Psychiatry 9, 1–17. https://doi.org/10.3389/fpsyt.2018.00406.
Disord. 26 (1), 39–51. https://doi.org/10.1080/10640266.2018.1418253.

501
S. Mattingley et al. Journal of Affective Disorders 300 (2022) 492–504

*Kiselica, A.M., Rojas, E., Bornovalova, M.A., Dube, C, 2015. The nomological network Racine, S.E., Vanhuysse, J.L., Keel, P.K., Burt, S.A., Neale, M.C., Boker, S., Klump, K.L.,
of self-reported distress tolerance. Assessment 22 (6), 715–729. https://doi.org/ 2017. Eating disorder-specific risk factors moderate the relationship between
10.1177/1073191114559407. negative urgency and binge eating: a behavioural genetic investigation. J. Abnorm.
*Kiselica, A.M., Webber, T., Bornovalova, M.A, 2014. Stability and change in distress Psychol. 126 (5), 481–494. https://doi.org/10.1037/abn0000204.
tolerance and its prospective relationship with borderline personality features: a Raykos, B.C., Byrne, S.M., Watson, H., BC, R., SM, B., Watson, H., 2009. Confirmatory
short-term longitudinal study. Pers. Disord.: Theory Res. Treat. 5 (3), 247–256. and exploratory factor analysis of the distress tolerance scale (DTS) in a clinical
https://doi.org/10.1037/per0000076. sample of eating disorder patients. Eat. Behav. 10 (4), 215–219. https://doi.org/
Kober, H., 2014. Emotion regulation in substance use disorders. In: Gross, J.J. (Ed.), 10.1016/j.eatbeh.2009.07.001.
Handbook of Emotion Regulation, 2nd ed. The Guilford Press, pp. 428–446. Rette, D.N., Arnold, M.S., McDonald, E.M., Hoptman, M.J., Collins, K.A., Iosifescu, D.V.,
*Lampard, A.M., Byrne, S.M., McLean, N., Fursland, A, 2011a. Avoidance of affect in the 2021. Influences on childhood depressive symptoms: the effects of trauma and
eating disorders. Eat. Behav. 12 (1), 90–93. https://doi.org/10.1016/j. distress tolerance across age and sex groups. J. Affect. Disord. 283, 373–376. https://
eatbeh.2010.11.004. doi.org/10.1016/j.jad.2021.01.064.
Laposa, J.M., Collimore, K.C., Hawley, L.L., Rector, N.A., 2015. Distress tolerance in OCD Ritschel, L.A., Lim, N.E., Stewart, L.M., 2015. Transdiagnostic applications of DBT for
and anxiety disorders, And its relationship with anxiety sensitivity and intolerance of adolescents and adults. Am. J. Psychother. 69 (2), 111–128. https://doi.org/
uncertainty. J. Anxiety Disord. 33, 8–14. https://doi.org/10.1016/j. 10.1176/appi.psychotherapy.2015.69.2.111.
janxdis.2015.04.003. Rogers, T.A., Bardeen, J.R., Fergus, T.A., Benfer, N., 2020. Factor structure and
Lass, A.N.S., Winer, E.S., 2020. Distress tolerance and symptoms of depression: a review incremental utility of the distress tolerance scale: a bifactor analysis. Assessment 27
and integration of literatures. Clin. Psychol.: Sci. Practice 27 (3), 1–14. https://doi. (2), 297–308. https://doi.org/10.1177/1073191118789496.
org/10.1111/cpsp.12336. Russell, B.S., Hutchison, M., Fusco, A., 2019. Emotion regulation outcomes and
Lass, A.N.S., Winer, E.S., Collins, A.C., Rokke, P.D., 2020. The associations among preliminary feasibility evidence from a mindfulness intervention for adolescent
distress tolerance, unhelpful coping behaviors, and symptoms of depression: a substance use. J. Child Adolesc. Substance Abuse 28 (1), 21–31. https://doi.org/
network analysis. Cognit. Ther. Res. 44 (6), 1077–1090. https://doi.org/10.1007/ 10.1080/1067828X.2018.1561577.
s10608-020-10131-2. Sansone, R.A., Levitt, J.L., 2005. Borderline personality and eating disorders. Eat Disord.
Lavender, J.M., Utzinger, L.M., Cao, L., Wonderlich, S.A., Engel, S.G., Mitchell, J.E., 13 (1), 71–83. https://doi.org/10.1080/10640260590893665.
Crosby, R.D., 2016. Brief report: reciprocal associations between negative affect, Santangelo, P., Bohus, M., Ebner-Priemer, U.W., 2014. Ecological momentary assessment
binge eating, and purging in the natural environment in women with bulimia in borderline personality disorder: a review of recent findings and methodological
nervosa. J. Abnorm. Psychol. 125 (3), 1–6. https://doi.org/10.1037/abn0000135. challenges. J. Pers. Disord. 28 (4), 555–576. https://doi.org/10.1521/pedi_2012_26_
Lebeaut, A., Zegel, M., Leonard, S.J., Bartlett, B.A., Vujanovic, A.A., 2021. Examining 067.
transdiagnostic factors among firefighters in relation to trauma exposure, probable *Simons, J.S., Gaher, R.M, 2005. The distress tolerance scale: development and
PTSD, and probable alcohol use disorder. J. Dual Diagn. 17 (1), 52–63. https://doi. validation of a self-report measure. Motiv. Emot. 29 (2), 83–102. https://doi.org/
org/10.1080/15504263.2020.1854411. 10.1007/s11031-005-7955-3.
Lejuez, C.W., Kahler, C.W., Brown, R.A., 2003. A modified computer version of the Paced *Simons, J.S., Gaher, R.M., Oliver, M.N.I., Bush, J.A., Palmer, M.A, 2005. An experience
Auditory Serial Addition Task (PASAT) as a laboratory-based stressor. Behav. sampling study of associations between affect and alcohol use and problems among
Therapist 26 (4), 290–293. college students. J. Stud. Alcohol 66 (4), 459–469. https://doi.org/10.15288/
Leyro, T.M., Zvolensky, M.J., Bernstein, A., 2010. Distress tolerance and jsa.2005.66.459.
psychopathological symptoms and disorders: a review of the empirical literature Sloan, E., Hall, K., Youssef, G.J., Moulding, R., Mildred, H., Staiger, P.K., 2019. Profiles of
among adults. Psychol. Bull. 136 (4), 576–600. https://doi.org/10.1037/a0019712. emotion regulation in young people accessing youth mental health and drug
Linehan, M.M., 1993. Cognitive-behavioral treatment of borderline personality disorder. treatment. Cognit. Ther. Res. 43 (4), 769–780. https://doi.org/10.1007/s10608-
Guildford Publications. 019-10003-4.
Marchette, L.K., Weisz, J.R., 2017. Practitioner Review: empirical evolution of youth Sobell, L.C., Sobell, M.G., 1992. Timeline follow-back: a technique for assessing self-
psychotherapy toward transdiagnostic approaches. J. Child Psychol. Psychiatry 58 reported alcohol consumption. In: Litten, R.Z., Allen, J.P. (Eds.), Measuring alcohol
(9), 970–984. https://doi.org/10.1111/jcpp.12747. consumption. Humana Press, pp. 41–72.
Martin, C.S., Langenbucher, J.W., Chung, T., Sher, K.J., 2014. Truth or consequences in Smith, K.E., Mason, T.B., Juarascio, A., Weinbach, N., Dvorak, R., Crosby, R.D.,
the diagnosis of substance use disorders. Addiction 109 (11), 1773–1778. https:// Wonderlich, S.A., 2020. The momentary interplay of affect, attention bias, and
doi.org/10.1111/add.12615. expectancies as predictors of binge eating in the natural environment. Int. J. Eat.
Martin, P., Murray, L.K., Darnell, D., Dorsey, S., 2018. Transdiagnostic treatment Disord. 53 (4), 586–594. https://doi.org/10.1002/eat.23235.
approaches for greater public health impact: implementing principles of evidence- Tanner-Smith, E.E., Tipton, E., 2014. Robust variance estimation with dependent effect
based mental health interventions. Clin. Psychol.: Sci. Practice 25 (4), 1–13. https:// sizes: practical considerations including a software tutorial in Stata and SPSS. Res.
doi.org/10.1111/cpsp.12270. Synth. Methods 5 (1), 13–30. https://doi.org/10.1002/jrsm.1091.
McHugh, R.K., Daughters, S.B., Lejuez, C.W., Murray, H.W., Hearon, B.A., Gorka, S.M., Tanner-Smith, E.E., Tipton, E., Polanin, J.R., 2016. Handling complex meta-analytic data
Otto, M.W., 2011. Shared variance among self-report and behavioral measures of structures using robust variance estimates: a Tutorial in R. J. Dev. Life Course
distress intolerance. Cognit. Ther. Res. 35 (3), 266–275. https://doi.org/10.1007/ Criminol. 2 (1), 85–112. https://doi.org/10.1007/s40865-016-0026-5.
s10608-010-9295-1. Tipton, E., 2013. Robust variance estimation in meta-regression with binary dependent
McHugh, R.K., Kneeland, E.T., 2019. Affective vulnerability in substance use disorders. effects. Res. Synth. Methods 4 (2), 169–187. https://doi.org/10.1002/jrsm.1070.
Curr. Opin. Psychol. 30, 54–58. https://doi.org/10.1016/j.copsyc.2019.01.011. Tomko, R.L., Trull, T.J., Wood, P.K., Sher, K.J., 2014. Characteristics of borderline
*McHugh, R.K., Otto, M.W, 2012. Refining the measurement of distress intolerance. personality disorder in a community sample: comorbidity, treatment utilization, and
Behav. Ther. 43 (3), 641–651. https://doi.org/10.1016/j.beth.2011.12.001. general functioning. J. Pers. Disord. 28 (5), 734–750. https://doi.org/10.1521/pedi_
McIntosh, R., Ironson, G., Krause, N., 2021. Keeping hope alive: racial-ethnic disparities 2012_26_093.
in distress tolerance are mitigated by religious/spiritual hope among Black Tonarely, N.A., Ehrenreich-May, J., 2020. Confirming the factor structure and validity of
Americans. J. Psychosom. Res. 144, 110403 https://doi.org/10.1016/j. the distress tolerance scale (DTS) in youth. Child Psychiatry Hum. Dev. 51 (4),
jpsychores.2021.110403. 514–526. https://doi.org/10.1007/s10578-019-00935-z.
McLaughlin, K.A., Colich, N.L., Rodman, A.M., Weissman, D.G., 2020. Mechanisms Trull, T.J., Freeman, L.K., Vebares, T.J., Choate, A.M., Helle, A.C., Wycoff, A.M., 2018.
linking childhood trauma exposure and psychopathology: a transdiagnostic model of Borderline personality disorder and substance use disorders: an updated review.
risk and resilience. BMC Med. 18 (1), 1–11. https://doi.org/10.1186/s12916-020- Borderline Pers. Disord. Emot. Dysregul. 5 (1), 1–12. https://doi.org/10.1186/
01561-6. s40479-018-0093-9.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., The PRISMA Group, 2009. Preferred Veilleux, J.C., 2019. The relationship between distress tolerance and cigarette smoking: a
reporting items for systematic reviews and meta-analyses: The PRISMA statement. systematic review and synthesis. Clin. Psychol. Rev. 71, 78–89. https://doi.org/
PLoS Med. 6 (7), 1–6. https://doi.org/10.1371/journal.pmed.1000097 e10000097. 10.1016/j.cpr.2019.01.003.
Molendijk, M.L., Hoek, H.W., Brewerton, T.D., Elzinga, B.M., 2017. Childhood Viechtbauer, W., 2010. Conducting meta-analyses in R with the metafor. J. Stat. Softw.
maltreatment and eating disorder pathology: a systematic review and dose-response 36 (3), 1–48. https://doi.org/10.18637/jss.v036.i03.
meta-analysis. Psychol. Med. 47 (8), 1402–1416. https://doi.org/10.1017/ Vujanovic, A.A., Smith, L.J., Green, C.E., Lane, S.D., Schmitz, J.M., 2018a. Development
S0033291716003561. of a novel, integrated cognitive-behavioral therapy for co-occurring posttraumatic
*Mountford, V., Corstorphine, E., Tomlinson, S., Waller, G, 2007. Development of a stress and substance use disorders: a pilot randomized clinical trial. Contemp. Clin.
measure to assess invalidating childhood environments in the eating disorders. Eat. Trials 65, 123–129. https://doi.org/10.1016/j.cct.2017.12.013.
Behav. 8 (1), 48–58. https://doi.org/10.1016/j.eatbeh.2006.01.003. Warner, N., Murphy, M., 2013. Dialectical behaviour therapy skills training for
Ouzzani, M., Hammady, H., Fedorowicz, Z., Elmagarmid, A., 2016. Rayyan-a web and individuals with substance usedisorder: a systematic review. Drug Alcohol Rev. 14
mobile app for systematic reviews. Syst. Rev. 5 (1), 1–10. https://doi.org/10.1186/ (2), 1–16. https://doi.org/10.1111/dar.13362.
s13643-016-0384-4. Winkler, L.A.D., Christiansen, E., Lichtenstein, M.B., Hansen, N.B., Bilenberg, N.,
*Özdel, K., Ekinci, S, 2014. Distress intolerance in substance dependent patients. Compr. Støving, R.K., 2014. Quality of life in eating disorders: a meta-analysis. Psychiatry
Psychiatry 55 (4), 960–965. https://doi.org/10.1016/j.comppsych.2013.12.012. Res. 219 (1), 1–9. https://doi.org/10.1016/j.psychres.2014.05.002.
R Core Team. (2017). R: a language and environment for statistical computing: r Foundation *Wolitzky-Taylor, K., McBeth, J., Guillot, C.R., Stone, M.D., Kirkpatrick, M.G.,
for Statistical Computing. https://www.r-project.org/. Zvolensky, M.J., Buckner, J.D., Leventhal, A.M, 2016. Transdiagnostic processes
Racine, S.E., Martin, S.J., 2016. Exploring divergent trajectories: disorder-specific linking anxiety symptoms and substance use problems among adolescents. J. Addict.
moderators of the association between negative urgency and dysregulated eating. Dis. 35 (4), 266–277. https://doi.org/10.1080/10550887.2016.1207969.
Appetite 103, 45–53. https://doi.org/10.1016/j.appet.2016.03.021. Wright, I., Travers-Hill, E., Gracey, F., Troup, J., Parkin, K., Casey, S., Kim, Y., 2020. Brief
psychological intervention for distress tolerance in an adult secondary care

502
S. Mattingley et al. Journal of Affective Disorders 300 (2022) 492–504

community mental health service: an evaluation. Cognit. Behav. Therapist 13, 1–12. *Gorey, C.M., Rojas, E.A., Bornovalova, M.A, 2018. More of a good thing is not always
https://doi.org/10.1017/S1754470X20000513. better: validation of a distress overtolerance measure. Assessment 25 (4), 446–457.
Yang, M.J., Borges, A., Leyro, T.M., 2019. The sequential indirect effect of negative https://doi.org/10.1177/1073191116654218.
urgency on drinking consequences through distress intolerance and drinking *Himmerich, S., Orcutt, H, 2019. Alcohol expectancies and distress tolerance: potential
motives: initial examination in college students reporting past month alcohol use. mechanisms in the relationship between posttraumatic stress and alcohol use. Pers.
Int. J. Ment. Health Addict. 17 (3), 479–492. https://doi.org/10.1007/s11469-019- Individ. Dif. 137, 39–44. https://doi.org/10.1016/j.paid.2018.08.004.
00068-3. *Hovrud, L., Simons, R., Simons, J, 2020. Cognitive schemas and eating disorder risk: the
*Yiu, A., Christensen, K., Arlt, J.M., Chen, E.Y, 2018. Distress tolerance across self-report, role of distress tolerance. Int. J. Cogn. Ther. 13 (1), 54–66. https://doi.org/10.1007/
behavioral and psychophysiological domains in women with eating disorders, and s41811-019-00055-5.
healthy controls. J. Behav. Ther. Exp. Psychiatry 61, 24–31. https://doi.org/ *Howell, A.N., Leyro, T.M., Hogan, J., Buckner, J.D., Zvolensky, M.J, 2010. Anxiety
10.1016/j.jbtep.2018.05.006. sensitivity, distress tolerance, and discomfort intolerance in relation to coping and
Zapolski, T.C.B., Rowe, A.T., Banks, D.E., Faidley, M., 2019. Perceived discrimination conformity motives for alcohol use and alcohol use problems among young adult
and substance use among adolescents: examining the moderating effect of distress drinkers. Addict. Behav. 35 (12), 1144–1147. https://doi.org/10.1016/j.
tolerance and negative urgency. Subst. Use Misuse 54 (1), 156–165. https://doi.org/ addbeh.2010.07.003.
10.1080/10826084.2018.1512625. *Kaiser, A.J., Milich, R., Lynam, D.R., Charnigo, R.J, 2012. Negative urgency, distress
Zvolensky, M.J., Hogan, J., 2013. Distress tolerance and its role in psychopathology. tolerance, and substance abuse among college students. Addict. Behav. 37 (10),
Cognit. Ther. Res. 37 (3), 419–420. https://doi.org/10.1007/s10608-013-9533-4. 1075–1083. https://doi.org/10.1016/j.addbeh.2012.04.017.
*Koball, A.M., Himes, S.M., Sim, L., Clark, M.M., Collazo-Clavell, M.L., Mundi, M.,
Kellogg, T., Graszer, K., Grothe, K.B, 2016. Distress tolerance and psychological
Further reading comorbidity in patients seeking bariatric surgery. Obes. Surg. 26 (7), 1559–1564.
https://dx.doi.org/10.1007/s11695-015-1926-x.
*Ali, B., Ryan, J.S., Beck, K.H., Daughters, S.B, 2013. Trait aggression and problematic *Kuvaas, N.J., Dvorak, R.D., Pearson, M.R., Lamis, D.A., Sargent, E.M, 2014. Self-
alcohol use among college students: the moderating effect of distress tolerance. regulation and alcohol use involvement: a latent class analysis. Addict. Behav. 39
Alcoholism: Clin. Exp. Res. 37 (12), 2138–2144. https://doi.org/10.1111/ (1), 146–152. https://doi.org/10.1016/j.addbeh.2013.09.020.
acer.12198. *Lampard, A.M., Byrne, S.M., McLean, N., Fursland, A, 2011b. An evaluation of the
*Allen, K.L., McLean, N.J., Byrne, S.M., 2012. Evaluation of a new measure of mood enhanced cognitive-behavioural model of bulimia nervosa. Behav. Res. Ther. 49 (9),
intolerance, the Tolerance of Mood States Scale (TOMS): psychometric properties 529–535. https://doi.org/10.1016/j.brat.2011.06.002.
and associations with eating disorder symptoms. Eat. Behav. 13 (4), 326–334. *Lavender, J.M., Happel, K., Anestis, M.D., Tull, M.T., Gratz, K.L, 2015. The interactive
https://doi.org/10.1016/j.eatbeh.2012.05.005. role of distress tolerance and eating expectancies in bulimic symptoms among
*Anestis, M.D., Gratz, K.L., Bagge, C.L., Tull, M.T, 2012a. The interactive role of distress substance abusers. Eat. Behav. 16, 88–91. https://dx.doi.org/10.1016/j.eatbeh.20
tolerance and borderline personality disorder in suicide attempts among substance 14.10.006.
users in residential treatment. Compr. Psychiatry 53 (8), 1208–1216. https://dx.doi. *Iverson, K.M., Follette, V.M., Pistorello, J., Fruzzetti, A.E, 2012. An investigation of
org/10.1016/j.comppsych.2012.04.004. experiential avoidance, emotion dysregulation, and distress tolerance in young adult
*Anestis, M.D., Tull, M.T., Bagge, C.L., Gratz, K.L, 2012c. The moderating role of distress outpatients with borderline personality disorder symptoms. Pers. Disord.: Theory
tolerance in the relationship between posttraumatic stress disorder symptom clusters Res. Treat. 3 (4), 415–422. https://doi.org/10.1037/a0023703.
and suicidal behavior among trauma exposed substance users in residential *Macatee, R.J., Albanese, B.J., Crane, N.A., Okey, S.A., Cougle, J.R., Schmidt, N.B, 2018.
treatment. Arch. Suicide Res. 16 (3), 198–211. https://doi.org/10.1080/ Distress intolerance moderation of neurophysiological markers of response
13811118.2012.695269. inhibition after induced stress: relations with cannabis use disorder. Psychol. Addict.
*Bonfils, K.A., Lysaker, P.H, 2020. Levels of distress tolerance in schizophrenia appear Behav. 32 (8), 944–955. https://doi.org/10.1037/adb0000418.
equivalent to those found in borderline personality disorder. J. Clin. Psychol. 76 (9), *Manning, K., Paulus, D.J., Hogan, J.B.D., Buckner, J.D., Farris, S.G., Zvolensky, M.J,
1668–1676. https://doi.org/10.1002/jclp.22944. 2018. Negative affectivity as a mechanism underlying perceived distress tolerance
*Bornovalova, M.A., Matusiewicz, A., Rojas, E, 2011. Distress tolerance moderates the and cannabis use problems, barriers to cessation, and self-efficacy for quitting among
relationship between negative affect intensity with borderline personality disorder urban cannabis users. Addict. Behav. 78, 216–222. https://doi.org/10.1016/j.
levels. Compr. Psychiatry 52 (6), 744–753. https://dx.doi.org/10.1016/j.co addbeh.2017.11.041.
mppsych.2010.11.005. *Manser, R., Cooper, M., Trefusis, J, 2012. Beliefs about emotions as a metacognitive
*Brooks Holliday, S., Pedersen, E.R., Leventhal, A.M., 2016. Depression, posttraumatic construct: initial development of a self-report questionnaire measure and
stress, and alcohol misuse in young adult veterans: the transdiagnostic role of preliminary investigation in relation to emotion regulation. Clin. Psychol.
distress tolerance. Drug Alcohol Depend. 161, 348–355. https://doi.org/10.1016/j. Psychother. 19 (3), 235–246. https://doi.org/10.1002/cpp.745.
drugalcdep.2016.02.030. *Marshall-Berenz, E.C., Vujanovic, A.A., MacPherson, L, 2011. Impulsivity and alcohol
*Burr, E.K., O’Keeffe, B., Kibbey, M.M., Coniglio, K.A., Leyro, T.M., Farris, S.G, 2020. use coping motives in a trauma-exposed sample: the mediating role of distress
Distress intolerance in relation to reliance on cigarettes for weight, shape, and tolerance. Pers. Individ. Dif. 50 (5), 588–592. https://doi.org/10.1016/j.
appetite control. Int. J. Behav. Med. 27 (2), 247–254. https://doi.org/10.1007/ paid.2010.11.033.
s12529-020-09858-9. *McHugh, R.K., Weiss, R.D., Cornelius, M., Martel, M.O., Jamison, R.N., Edwards, R.R,
*Caselli, G., Canfora, F., Ruggiero, G.M., Sassaroli, S., Albery, I.P., Spada, M.M, 2015. 2016. Distress intolerance and prescription opioid misuse among patients with
Desire thinking mediates the relationship between emotional intolerance and chronic pain. J. Pain 17 (7), 806–814. https://doi.org/10.1016/j.jpain.2016.03.004.
problem drinking. Int J Ment Health Addict 13 (2), 185–193. https://doi.org/ *McMain, S.F., Guimond, T., Barnhart, R., Habinski, L., Streiner, D.L, 2017.
10.1007/s11469-014-9520-3. A randomized trial of brief dialectical behaviour therapy skills training in suicidal
*Chung, J.J., Wakefield, M.A., Austin, S.B., Chapman, A.L, 2020. Smiling to tolerate patients suffering from borderline disorder. Acta Psychiatr. Scand. 135 (2), 138–148.
distress: the moderating role of attention to emotion. Canadian Journal of https://doi.org/10.1111/acps.12664.
Behavioural Science 53 (1), 59–70. https://doi.org/10.1037/cbs0000188. *Peraza, N., Smit, T., Garey, L., Manning, K., Buckner, J.D., Zvolensky, M.J, 2019.
*Cohen, J.R., Danielson, C.K., Adams, Z.W., Ruggiero, K.J, 2016. Distress tolerance and Distress tolerance and cessation-related cannabis processes: the role of cannabis use
social support in adolescence: predicting risk for internalizing and externalizing coping motives. Addict. Behav. 90, 164–170. https://doi.org/10.1016/j.
symptoms following a natural disaster. J Psychopathol Behav Assess 38 (4), addbeh.2018.10.047.
538–546. https://dx.doi.org/10.1007/s10862-016-9545-y. *Quinn, E.P., Brandon, T.H., Copeland, A.L, 1996. Is task persistence related to smoking
*Conway, C.C., Penrod, M.T., Pugsley, G.M., Larrazabal, M.A., Snyder, C.E, 2019. Cross- and substance abuse? The application of learned industriousness theory to addictive
domain assessment of distress intolerance: associations with borderline personality behaviors. Exp. Clin. Psychopharmacol. 4 (2), 186–190. https://doi.org/10.1037/
disorder features. J. Pers. Disord. 33 (4), 560–575. https://doi.org/10.1521/pedi_ 1064-1297.4.2.186.
2018_32_359. *Reilly, M.E., Hines, D.A, 2020. Distress tolerance as a mediator of the association
*Dennhardt, A.A., Murphy, J.G, 2011. Associations between depression, distress between borderline personality symptoms and obsessive relational intrusion: an
tolerance, delay discounting, and alcohol-related problems in european american exploratory analysis. J. Interpers. Violence 35 (19), 3833–3848. https://doi.org/
and african american college students. Psychol. Addict. Behav. 25 (4), 595–604. 10.1177/0886260517712274.
https://doi.org/10.1037/a0025807. *Rojas, E.C., Hicks, B.M., Stark, S., Hopwood, C.J., Bornovalova, M.A, 2015. Elaborating
*Dixon-Gordon, K.L., Chapman, A.L., Turner, B.J, 2015. A preliminary pilot study on the construct validity of the Minnesota Borderline Personality Disorder Scale
comparing dialectical behavior therapy emotion regulation skills with interpersonal (MBPD): a multi-sample, longitudinal examination. Psychol. Assess. 27 (1),
effectiveness skills and a control group treatment. J. Exp. Psychopathol. 6 (4), 332–339. https://doi.org/10.1037/pas0000061.
369–388. https://doi.org/10.5127/jep.041714. *Rung, J.M., Johnson, P.S., Madden, G.J, 2018. Differential relations between delay
*Duranceau, S., Fetzner, M., Carleton, R, 2014. Low distress tolerance and hyperarousal discounting and distress tolerance as a function of opportunity cost and alcohol use.
posttraumatic stress disorder symptoms: a pathway to alcohol use? Cogn. Ther. Res. Exp. Clin. Psychopharmacol. 26 (3), 278–289. https://doi.org/10.1037/
38 (3), 280–290. https://doi.org/10.1007/s10608-013-9591-7. pha0000198.
*Gaher, R.M., Hofman, N.L., Simons, J.S., Hunsaker, R, 2013. Emotion regulation deficits *Seo, J.W., Kwon, S.M, 2016. Testing an affective judgment model of distress tolerance in
as mediators between trauma exposure and borderline symptoms. Cognit. Ther. Res. college heavy drinkers. Addict. Behav. 58, 100–103. https://dx.doi.org/10.1016/j.
37 (3), 466–475. https://doi.org/10.1007/s10608-012-9515-y. addbeh.2016.02.021.
*Garey, L., Bakhshaie, J., Sharp, C., Neighbors, C., Zvolensky, M.J., Gonzalez, A, 2015. *Shorey, R.C., Elmquist, J., Strauss, C., Anderson, S.E., Stuart, G.L, 2016. Research
Anxiety, depression, and HIV symptoms among persons living with HIV/AIDS: the reactions following participation in intimate partner violence research: an
role of hazardous drinking. AIDS Care 27 (1), 80–85. https://doi.org/10.1080/ examination with men in substance use treatment. J. Interpers. Violence 31 (19),
09540121.2014.956042. 3196–3210. https://doi.org/10.1177/0886260515584345.

503
S. Mattingley et al. Journal of Affective Disorders 300 (2022) 492–504

*Shorey, R.C., Gawrysiak, M.J., Elmquist, J., Brem, M., Anderson, S., Stuart, G.L, 2017. cocaine-dependent adults. Behav. Modif. 40 (1), 120–143. https://doi.org/10.11
Experiential avoidance, distress tolerance, and substance use cravings among adults 77/0145445515621490.
in residential treatment for substance use disorders. J. Addict. Dis. 36 (3), 151–157. *Vujanovic, A.A., Wardle, M.C., Bakhshaie, J., Smith, L.J., Green, C.E., Lane, S.D.,
https://doi.org/10.1080/10550887.2017.1302661. Schmitz, J.M, 2018b. Distress tolerance: associations with trauma and substance cue
*Simons, R.M., Sistad, R.E., Simons, J.S., Hansen, J, 2018. The role of distress tolerance reactivity in low-income, inner-city adults with substance use disorders and
in the relationship between cognitive schemas and alcohol problems among college posttraumatic stress. Psychol. Addict. Behav. 32 (3), 264–276. https://doi.org/
students. Addict. Behav. 78, 1–8. https://doi.org/10.1016/j.addbeh.2017.10.020. 10.1037/adb0000362.
*Smith, L.J., Bartlett, B.A., Tran, J.K., Gallagher, M.W., Alfano, C., Vujanovic, A.A, 2019. *Wang, K., White Hughto, J.M., Biello, K.B., O’Cleirigh, C., Mayer, K.H., Rosenberger, J.
Sleep disturbance among firefighters: understanding associations with alcohol use G., Novak, D.S., Mimiaga, M.J, 2017. The role of distress intolerance in the
and distress tolerance. Cognit. Ther. Res. 43 (1), 66–77. https://doi.org/10.1007/ relationship between childhood sexual abuse and problematic alcohol use among
s10608-018-9955-0. Latin American MSM. Drug Alcohol Depend. 175, 151–156. https://doi.org/
*Sturrock, B.A., Francis, A., Carr, S, 2009. Avoidance of affect mediates the effect of 10.1016/j.drugalcdep.2017.02.004.
invalidating childhood environments on borderline personality symptomatology in a *Webb, J.B., Forman, M.J, 2013. Evaluating the indirect effect of self-compassion on
non-clinical sample. Clin. Psychologist 13 (2), 41–51. https://doi.org/10.1080/ binge eating severity through cognitive-affective self-regulatory pathways. Eat.
13284200902936927. Behav. 14 (2), 224–228. https://dx.doi.org/10.1016/j.eatbeh.2012.12.005.
*Sturrock, B., Mellor, D, 2014. Perceived emotional invalidation and borderline *Williams, C.L., Vik, P.W., Wong, M.M, 2015. Distress tolerance in social versus solitary
personality disorder features: a test of theory. Pers. Ment. Health 8 (2), 128–142. college student drinkers. Addict. Behav. 50, 89–95. https://doi.org/10.1016/j.
https://doi.org/10.1002/pmh.1249. addbeh.2015.06.025.
*Veilleux, J.C., Pollert, G.A., Zielinski, M.J., Shaver, J.A., Hill, M.A, 2019. Behavioral *Wolitzky-Taylor, K., Guillot, C.R., Pang, R.D., Kirkpatrick, M.G., Zvolensky, M.J.,
assessment of the negative emotion aspect of distress tolerance: tolerance to Buckner, J.D., Leventhal, A.M, 2015. Examination of anxiety sensitivity and distress
emotional images. Assessment 26 (3), 386–403. https://doi.org/10.1177/ tolerance as transdiagnostic mechanisms linking multiple anxiety pathologies to
1073191116689819. alcohol use problems in adolescents. Alcoholism: Clin. Exp. Res. 39 (3), 532–539.
*Vinci, C., Mota, N., Berenz, E., Kevin Connolly, G.V., 2016. Examination of the https://doi.org/10.1111/acer.12638.
relationship between PTSD and distress tolerance in a sample of male veterans with *Zegel, M., Rogers, A.H., Vujanovic, A.A., Zvolensky, M.J, 2021. Alcohol use problems
comorbid substance use disorders. Military Psychol. 28 (2), 104–114. https://doi. and opioid misuse and dependence among adults with chronic pain: the role of
org/10.1037/mil0000100. distress tolerance. Psychol. Addict. Behav. 35 (1), 42–51. https://doi.org/10.1037/
*Vujanovic, A.A., Marshall-Berenz, E.C., Zvolensky, M.J, 2011. Posttraumatic stress and adb0000587.
alcohol use motives: a test of the incremental and mediating role of distress *Zvolensky, M.J., Marshall, E.C., Johnson, K., Hogan, J., Bernstein, A., Bonn-Miller, M.O,
tolerance. J. Cogn. Psychother. 25 (2), 130–141. https://doi.org/10.1891/0889- 2009. Relations between anxiety sensitivity, distress tolerance, and fear reactivity to
8391.25.2.130. bodily sensations to coping and conformity marijuana use motives among young
*Vujanovic, A.A., Rathnayaka, N., Amador, C.D., Schmitz, J.M, 2016. Distress tolerance: adult marijuana users. Exp. Clin. Psychopharmacol. 17 (1), 31–42. https://doi.org/
associations with posttraumatic stress disorder symptoms among trauma-exposed, 10.1037/a0014961.

504