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Direct and Interactive Effects of Distress Tolerance and Anxiety Sensitivity on Generalized Anxiety and Depression

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Abstract

Anxiety sensitivity and distress tolerance are both hypothesized risk factors for generalized anxiety disorder (GAD) and major depressive disorder (MDD). However, it is unclear whether these factors synergistically influence GAD and MDD and related symptoms. Using latent variable methods, direct and interactive relations between anxiety sensitivity and distress tolerance with worry and depressive symptoms and with GAD and MDD diagnoses were examined in 347 outpatients. Interactive effects of anxiety sensitivity and distress tolerance were found for worry and GAD/MDD. The interactions generally suggested that anxiety sensitivity confers a greater risk for worry and GAD/MDD at higher levels of distress tolerance, and that distress tolerance confers a greater risk for worry and GAD/MDD at lower levels of anxiety sensitivity. Given the interactive effects of anxiety sensitivity and distress tolerance for GAD/MDD, interventions targeting both risk factors may prove more efficacious than targeting each individually.

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References

  • Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. London: Sage.

    Google Scholar 

  • Allan, N. P., Capron, D. W., Lejuez, C. W., Reynolds, E. K., MacPherson, L., & Schmidt, N. B. (2014a). Developmental trajectories of anxiety symptoms in early adolescence: The influence of anxiety sensitivity. Journal of Abnormal Child Psychology, 42, 589–600.

    Article  PubMed  Google Scholar 

  • Allan, N. P., Capron, D. W., Raines, A. M., & Schmidt, N. B. (2014b). Unique relations among anxiety sensitivity factors and anxiety, depression, and suicidal ideation. Journal of Anxiety Disorders, 2, 266–275.

    Article  Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

    Google Scholar 

  • Amstadter, A. B., Daughters, S. B., MacPherson, L., Reynolds, E. K., Danielson, C. K., Wang, F., et al. (2012). Genetic associations with performance on a behavioral measure of distress intolerance. Journal of Psychiatric Research, 46, 87–94.

    Article  PubMed  PubMed Central  Google Scholar 

  • Anestis, M. D., Gratz, K. L., Bagge, C. L., & Tull, M. T. (2012). The interactive role of distress tolerance and borderline personality disorder in suicide attempts among substance users in residential treatment. Comprehensive Psychiatry, 53, 1208–1216.

    Article  PubMed  Google Scholar 

  • Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.

    Google Scholar 

  • Beesdo, K., Pine, D. S., Lieb, R., & Wittchen, H. (2010). Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Archives of General Psychiatry, 67, 47–57.

    Article  PubMed  Google Scholar 

  • Bernstein, A., Zvolensky, M. J., Vujanovic, A. A., & Moos, R. (2009). Integrating anxiety sensitivity, distress tolerance, and discomfort intolerance: A hierarchical model of affect sensitivity and tolerance. Behavior Therapy, 40, 291–301.

    Article  PubMed  Google Scholar 

  • Bornovalova, M. A., Gratz, K. L., Daughters, S. B., Hunt, E. D., & Lejuez, C. W. (2012). Initial RCT of a distress tolerance treatment for individuals with substance use disorders. Drug and Alcohol Dependence, 122, 70–76.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brown, T. A. (2003). Confirmatory factor analysis of the Penn State Worry Questionnaire: Multiple factors or method effects? Behaviour Research and Therapy, 41, 1411–1426.

    Article  PubMed  Google Scholar 

  • Brown, R. A., Lejuez, C. W., Strong, D. R., Kahler, C. W., Zvolensky, M. J., Carpenter, L. L., et al. (2009). A prospective examination of distress tolerance and early smoking lapse in adult self-quitters. Nicotine & Tobacco Research, 11, 493–502.

    Article  Google Scholar 

  • Buckner, J. D., Keough, M. E., & Schmidt, N. B. (2007). Problematic alcohol and cannabis use among young adults: The roles of depression and discomfort and distress tolerance. Addictive Behaviors, 32, 1957–1963.

    Article  PubMed  PubMed Central  Google Scholar 

  • Capron, D. W., Norr, A. M., Macatee, R. J., & Schmidt, N. B. (2013). Distress tolerance and anxiety sensitivity cognitive concerns: Testing the incremental contributions of affect dysregulation constructs on suicidal ideation and suicide attempt. Behavior Therapy, 44, 349–358.

    Article  PubMed  Google Scholar 

  • Carter, R. M., Wittchen, H.-U., Pfister, H., & Kessler, R. C. (2001). One-year prevalence of subthreshold and threshold DSM-IV generalized anxiety disorder in a nationally representative sample. Depression and Anxiety, 13, 78–88.

    Article  PubMed  CAS  Google Scholar 

  • Cox, B. J., Enns, M. W., Freeman, P., & Walker, J. R. (2001). Anxiety sensitivity and major depression: Examination of affective state dependence. Behaviour Research and Therapy, 39, 1349–1356.

    Article  PubMed  CAS  Google Scholar 

  • Cox, B. J., Taylor, S., & Enns, M. W. (1999). Fear of cognitive dyscontrol in relation to depression symptoms: Comparisons between original and alternative measures of anxiety sensitivity. Journal of Behavior Therapy and Experimental Psychiatry, 30, 301–311.

    Article  PubMed  CAS  Google Scholar 

  • Cummings, J. R., Bornovalova, M. A., Ojanen, T., Hunt, E., MacPherson, L., & Lejuez, C. (2013). Time doesn’t change everything: The longitudinal course of distress tolerance and its relationship with externalizing and internalizing symptoms during early adolescence. Journal of Abnormal Child Psychology, 41, 735–748.

    Article  PubMed  PubMed Central  Google Scholar 

  • Curran, P. J., West, S. G., & Finch, J. F. (1996). The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis. Psychological Methods, 1, 16–29.

    Article  Google Scholar 

  • Dennhardt, A. A., & Murphy, J. G. (2011). Associations between depression, distress tolerance, delay discounting, and alcohol-related problems in European American and African American college students. Psychology of Addictive Behaviors, 25, 595–604.

    Article  PubMed  Google Scholar 

  • Ellis, A. J., Fischer, K. M., & Beevers, C. G. (2010). Is dysphoria about being red and blue? Potentiation of anger and reduced distress tolerance among dysphoric individuals. Cognition and Emotion, 24, 596–608.

    Article  Google Scholar 

  • First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1997). Structured clinical interview for DSM-IV Axis I (SCID-I), clinician version. Washington, DC: American Psychiatric Press.

    Google Scholar 

  • Garber, J., & Hollon, S. D. (1991). What can specificity designs say about causality in psychopathology research? Psychological Bulletin, 110, 129–136.

  • Gorka, S. M., Ali, B., & Daughters, S. B. (2012). The role of distress tolerance in the relationship between depressive symptoms and problematic alcohol use. Psychology of Addictive Behaviors, 26, 621–626.

    Article  PubMed  PubMed Central  Google Scholar 

  • Grant, D. M., Beck, J. G., & Davila, J. (2007). Does anxiety sensitivity predict symptoms of panic, depression, and social anxiety? Behaviour Research and Therapy, 45, 2247–2255.

    Article  PubMed  Google Scholar 

  • Hettema, J. M. (2008). What is the genetic relationship between anxiety and depression? In American journal of medical genetics part C: Seminars in medical genetics (Vol. 148, pp. 140–146). Wiley Online Library. Retrieved from http://onlinelibrary.wiley.com.proxy.lib.fsu.edu/doi/1.1002/ajmg.c.30171/full.

  • Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6, 1–55.

    Article  Google Scholar 

  • Huang, K., Szabo, M., & Han, J. (2009). The relationship of low distress tolerance to excessive worrying and cognitive avoidance. Behaviour Change, 26, 223–234.

    Article  Google Scholar 

  • Jaccard, J., & Wan, C. K. (1995). Measurement error in the analysis of interaction effects between continuous predictors using multiple regression: Multiple indicator and structural equation approaches. Psychological Bulletin, 117, 348–357.

    Article  Google Scholar 

  • Kendler, K. S., Gardner, C. O., Gatz, M., & Pedersen, N. L. (2007). The sources of co-morbidity between major depression and generalized anxiety disorder in a Swedish national twin sample. Psychological Medicine, 37, 453–462.

    Article  PubMed  Google Scholar 

  • Kenny, D. A., & McCoach, D. B. (2003). Effect of the number of variables on measures of fit in structural equation modeling. Structural Equation Modeling, 10, 333–351.

    Article  Google Scholar 

  • Keough, M. E., Riccardi, C. J., Timpano, K. R., Mitchell, M. A., & Schmidt, N. B. (2010). Anxiety symptomatology: The association with distress tolerance and anxiety sensitivity. Behavior Therapy, 41, 567–574.

    Article  PubMed  Google Scholar 

  • Keough, M. E., & Schmidt, N. B. (2012). Refinement of a brief anxiety sensitivity reduction intervention. Journal of Consulting and Clinical Psychology, 80, 766–772.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kessler, R. C., DuPont, R. L., Berglund, P., & Wittchen, H.-U. (1999). Impairment in pure and comorbid generalized anxiety disorder and major depression at 12 months in two national surveys. American Journal of Psychiatry, 156, 1915–1923.

    PubMed  CAS  Google Scholar 

  • Kessler, R. C., McGonagle, K. A., Swartz, M., Blazer, D. G., & Nelson, C. B. (1993). Sex and depression in the National Comorbidity Survey I: Lifetime prevalence, chronicity and recurrence. Journal of Affective Disorders, 29, 85–96.

    Article  PubMed  CAS  Google Scholar 

  • Kleiman, E. M., & Riskind, J. H. (2012). Cognitive vulnerability to comorbidity: Looming cognitive style and depressive cognitive style as synergistic predictors of anxiety and depression symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 43, 1109–1114.

    Article  PubMed  Google Scholar 

  • Klein, A. G., & Muthén, B. O. (2007). Quasi-maximum likelihood estimation of structural equation models with multiple interaction and quadratic effects. Multivariate Behavioral Research, 42, 647–673.

    Article  Google Scholar 

  • Kline, R. B. (2011). Principles and practice of structural equation modeling (3rd ed.). New York, NY: The Guilford Press.

    Google Scholar 

  • Kuzma, J. M., & Black, D. W. (2004). Integrating pharmacotherapy and psychotherapy in the management of anxiety disorders. Current Psychiatry Reports, 6, 268–273.

    Article  PubMed  Google Scholar 

  • Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psychopathological symptoms and disorders: A review of the empirical literature among adults. Psychological Bulletin, 136, 576–600.

    Article  PubMed  PubMed Central  Google Scholar 

  • Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Inter-rater reliability of the structured clinical interview for DSM-IV Axis I disorders (SCID-I) and Axis II disorders (SCID II). Clinical Psychology and Psychotherapy, 18, 75–79.

    Article  PubMed  Google Scholar 

  • Macatee, R. J., Capron, D. W., Guthrie, W., Schmidt, N. B., & Cougle, J. R. (2014). Distress tolerance and pathological worry: Incremental contributions and prospective associations (submitted).

  • MacCallum, R. C., & Austin, J. T. (2000). Applications of structural equation modeling in psychological research. Annual Review of Psychology, 51, 201–226.

    Article  PubMed  CAS  Google Scholar 

  • MacCallum, R. C., Browne, M. W., & Sugawara, H. M. (1996). Power analysis and determination of sample size for covariance structure modeling. Psychological Methods, 1, 130–149.

    Article  Google Scholar 

  • McHugh, R. K., & Otto, M. W. (2012). Refining the measurement of distress intolerance. Behavior Therapy, 43, 641–651.

    Article  PubMed  PubMed Central  Google Scholar 

  • McHugh, R. K., Reynolds, E. K., Leyro, T. M., & Otto, M. W. (2013). An examination of the association of distress intolerance and emotion regulation with avoidance. Cognitive Therapy and Research, 37, 363–367.

    Article  Google Scholar 

  • Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487–495.

    Article  PubMed  CAS  Google Scholar 

  • Mitchell, M. A., Riccardi, C. J., Keough, M. E., Timpano, K. R., & Schmidt, N. B. (2013). Understanding the associations among anxiety sensitivity, distress tolerance, and discomfort intolerance: A comparison of three models. Journal of Anxiety Disorders, 27, 147–154.

    Article  PubMed  Google Scholar 

  • Moffitt, T. E., Harrington, H., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., et al. (2007). Depression and generalized anxiety disorder: Cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Archives of General Psychiatry, 64, 651–660.

    Article  PubMed  Google Scholar 

  • Moshagen, M. (2012). The model size effect in SEM: Inflated goodness-of-fit statistics are due to the size of the covariance matrix. Structural Equation Modeling: A Multidisciplinary Journal, 19, 86–98.

    Article  Google Scholar 

  • Muthén, L. K., & Muthén, B. O. (1998–2008). Mplus user’s guide (5th ed.) Los Angeles, CA: Author.

  • Naragon-Gainey, K. (2010). Meta-analysis of the relations of anxiety sensitivity to the depressive and anxiety disorders. Psychological Bulletin, 136, 128–150.

    Article  PubMed  Google Scholar 

  • Norr, A. M., Oglesby, M. E., Capron, D. W., Raines, A. M., Korte, K. J., & Schmidt, N. B. (2013). Evaluating the unique contribution of intolerance of uncertainty relative to other cognitive vulnerability factors in anxiety psychopathology. Journal of Affective Disorders, 151, 136–142.

    Article  PubMed  Google Scholar 

  • Olatunji, B. O., & Wolitzky-Taylor, K. B. (2009). Anxiety sensitivity and the anxiety disorders: A meta-analytic review and synthesis. Psychological Bulletin, 135, 974–999.

    Article  PubMed  Google Scholar 

  • Osman, A., Downs, W. R., Barrios, F. X., Kopper, B. A., Guttierrez, P. M., & Chiros, C. E. (1997). Factor structure and psychometric characteristics of the Beck Depression Inventory-II. Journal of Psychopathology and Behavioral Assessment, 19, 359–376.

    Article  Google Scholar 

  • Otto, M. W., Pollack, M. H., Fava, M., Uccello, R., & Rosenbaum, J. F. (1995). Elevated Anxiety Sensitivity Index scores in patients with major depression: Correlates and changes with antidepressant treatment. Journal of Anxiety Disorders, 9, 117–123.

    Article  Google Scholar 

  • Rector, N. A., Szacun-Shimizu, K., & Leybman, M. (2007). Anxiety sensitivity within the anxiety disorders: Disorder-specific sensitivities and depression comorbidity. Behaviour Research and Therapy, 45, 1967–1975.

    Article  PubMed  Google Scholar 

  • Reiss, S., & McNally, R. J. (1985). The expectancy model of fear. In S. Reiss & R. R. Bootzin (Eds.), Theoretical issues in behavior therapy. New York: Academic Press.

    Google Scholar 

  • Reiss, S., Peterson, R. A., Gursky, D. M., & McNally, R. J. (1986). Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1–8.

    Article  PubMed  CAS  Google Scholar 

  • Riskind, J. H., Black, D., & Shahar, G. (2010). Cognitive vulnerability to anxiety in the stress generation process: Interaction between the looming cognitive style and anxiety sensitivity. Journal of Anxiety Disorders, 24(124), 128.

    Google Scholar 

  • Rodriguez, B. F., Bruce, S. E., Pagano, M. E., Spencer, M. A., & Keller, M. B. (2004). Factor structure and stability of the Anxiety Sensitivity Index in a longitudinal study of anxiety disorder patients. Behaviour Research and Therapy, 42, 79–91.

    Article  PubMed  PubMed Central  Google Scholar 

  • Roy, M.-A., Neale, M. C., Pedersen, N. L., Mathe, A. A., & Kendler, K. S. (1995). A twin study of generalized anxiety disorder and major depression. Psychological Medicine, 25, 1037–1050.

    Article  PubMed  CAS  Google Scholar 

  • Schmidt, N. B., Capron, D. W., Raines, A. M., & Allan, N. P. (in press). Randomized clinical trial evaluating the efficacy of a brief intervention targeting anxiety sensitivity cognitive concerns. Journal of Consulting and Clinical Psychology.

  • Schmidt, N. B., Eggleston, A. M., Woolaway-Bickel, K., Fitzpatrick, K. K., Vasey, M. W., & Richey, J. A. (2007). Anxiety Sensitivity Amelioration Training (ASAT): A longitudinal primary prevention program targeting cognitive vulnerability. Journal of Anxiety Disorders, 21, 302–319.

    Article  PubMed  Google Scholar 

  • Schmidt, N. B., Lerew, D. R., & Joiner, T. E. (2000). Prospective evaluation of the etiology of anxiety sensitivity: Test of a scar model. Behaviour Research and Therapy, 38, 1083–1095.

    Article  PubMed  CAS  Google Scholar 

  • Schmidt, N. B., Zvolensky, M. J., & Maner, J. K. (2006). Anxiety sensitivity: Prospective prediction of panic attacks and Axis I pathology. Journal of Psychiatric Research, 40, 691–699.

    Article  PubMed  Google Scholar 

  • Simons, J. S., & Gaher, R. M. (2005). The Distress Tolerance Scale: Development and validation of a self-report measure. Motivation and Emotion, 29, 83–102.

    Article  Google Scholar 

  • Starr, L. R., & Davila, J. (2012). Responding to anxiety with rumination and hopelessness: Mechanism of anxiety-depression symptom co-occurrence? Cognitive Therapy and Research, 36, 321–337.

    Article  PubMed  PubMed Central  Google Scholar 

  • Stein, M. B., Jang, K. L., & Livesley, W. J. (1999). Heritability of anxiety sensitivity: A twin study. American Journal of Psychiatry, 156, 246–251.

    PubMed  CAS  Google Scholar 

  • Taylor, S., Koch, W. J., & McNally, R. J. (1992). How does anxiety sensitivity vary across the anxiety disorders. Journal of Anxiety Disorders, 6, 249–259.

    Article  Google Scholar 

  • Taylor, S., Koch, W. J., Woody, S., & McLean, P. (1996). Anxiety sensitivity and depression: How are they related? Journal of Abnormal Psychology, 105, 474–479.

    Article  PubMed  CAS  Google Scholar 

  • Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., et al. (2007). Robust dimensions of anxiety sensitivity: Development and initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19, 176–188.

    Article  PubMed  Google Scholar 

  • Tull, M. T., & Gratz, K. L. (2008). Further examination of the relationship between anxiety sensitivity and depression: The mediating role of experiential avoidance and difficulties engaging in goal-directed behavior when distressed. Journal of Anxiety Disorders, 22, 199–210.

    Article  PubMed  Google Scholar 

  • Vanheule, S., Desmet, M., Groenvynck, H., Rosseel, Y., & Fontaine, J. (2008). The factor structure of the Beck Depression Inventory-II: An evaluation. Assessment, 15, 177–187.

    Article  PubMed  Google Scholar 

  • Viana, A. G., & Rabian, B. (2008). Perceived attachment: Relations to anxiety sensitivity, worry, and GAD symptoms. Behaviour Research and Therapy, 46, 737–747.

    Article  PubMed  Google Scholar 

  • Watson, D., Gamez, W., & Simms, L. J. (2005). Basic dimensions of temperament and their relation to anxiety and depression: A symptom-based perspective. Journal of Research in Personality, 39, 46–66.

    Article  Google Scholar 

  • Williams, A. D., Thompson, J., & Andrews, G. (2013). The impact of psychological distress tolerance in the treatment of depression. Behaviour Research and Therapy, 51, 469–475.

    Article  PubMed  Google Scholar 

  • Zavos, H., Gregory, A. M., & Eley, T. C. (2012). Longitudinal genetic analysis of anxiety sensitivity. Developmental Psychology, 48, 204–212.

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors declare that there are no extramural funding sources. Data from this manuscript has previously been presented at the 34th Annual Conference of Anxiety and Depression Association of America, March 27-30, 2014, Chicago.

Conflict of Interest

Authors Allan, Macatee, Norr, and Schmidt declare that they have no conflict of interest.

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This study was approved by the Internal Review Board at the Florida State University. All participants provided informed consent prior to the completion of study measures.

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  1. Department of Psychology, Florida State University, P.O. Box 3064301, Tallahassee, FL, 32306-4301, USA

    Nicholas P. Allan, Richard J. Macatee, Aaron M. Norr & Norman B. Schmidt

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  1. Nicholas P. Allan
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Allan, N.P., Macatee, R.J., Norr, A.M. et al. Direct and Interactive Effects of Distress Tolerance and Anxiety Sensitivity on Generalized Anxiety and Depression. Cogn Ther Res 38, 530–540 (2014). https://doi.org/10.1007/s10608-014-9623-y

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