Integration of Cognitive Processing Therapy for PTSD and cognitive-behavioral therapy for co-occurring alcohol use disorder: Design and methodology of a randomized controlled trial.

The impact of a loss of control over threat on stress reactivity.

A pan-Canadian cluster randomized trial (by classroom) was conducted to examine the effects of a combined mental health literacy and dialectical behavior therapy skills program implemented by teachers on protective factors related to social and emotional well-being, including mindfulness, emotion regulation, inclusive education, distress tolerance, mental health knowledge, reduction of stigma, and help-seeking skills. The sample of 111 classrooms drawn from three urban centers and 67 schools, which were randomly assigned to intervention or control, included 1,750 students in third- to 12th-grade classrooms. Student-reported measures of mindfulness, emotion regulation, inclusive education, distress tolerance, mental health literacy, and classroom climate were collected three times in the year (October, February, and June). Teachers recorded dosage and fidelity data, and in-class observations took place to support implementation data. Results indicated the intervention classrooms demonstrated statistically significant improvements relative to the changes in the control classrooms on six of eight dependent variables: mindfulness, emotion regulation, impulse control, strategies, beliefs about mental illness, and stigma. Effect sizes were large for mindfulness, medium for emotion regulation and stigma, and small for impulse control and beliefs about mental illness. There was no evidence that intervention effects were moderated by intervention site, school level, or student characteristics related to Indigenous heritage, gender, or whether students received English language learner services. By contrast, the mid- to postintervention effect on mindfulness differed for students receiving special education services, such that effects were greater for students receiving special education services compared to students not receiving special education services. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

A transdiagnostic cognitive model of depression and anxiety in chronic inflammatory disease: Evidence from multiple sclerosis and endometriosis.

Generalized Anxiety Disorder (GAD) is one of the most common mental disorders. Current treatments often emphasize symptom reduction while neglecting key factors such as emotional distress tolerance and medication adherence. Metacognitive Therapy (MCT) provides a distinct approach by targeting maladaptive metacognitive beliefs that sustain anxiety and worry. This study aimed to evaluate the effectiveness of MCT in improving emotional distress tolerance and medication adherence among patients with GAD, with the goal of facilitating its clinical use by psychologists and psychiatrists. This study was conducted as a pilot randomized controlled trial with a pre-test/post-test design, comparing an intervention group to a waitlist control group. The sample included 32 outpatients aged 18-40 years diagnosed with GAD at Zareh Hospital's psychotherapy clinic. Participants were randomly assigned to an experimental group (n = 16) and a control group (n = 16). The experimental group received eight weekly sessions of Metacognitive Therapy (MCT), while the control group was placed on a waitlist and received no intervention during the study period. Data were collected using the Generalized Anxiety Disorder Scale, the Distress Tolerance Scale, and the Medication Adherence Measure. Data analysis was performed with SPSS version 26 using MANCOVA. Results showed that MCT significantly improved emotional distress tolerance. In the experimental group, the mean score increased from 30.94 ± 4.28 at pre-test to 52.75 ± 6.89 at post-test (95% CI for estimated marginal mean: 52.06-55.47), while in the control group the mean score changed from 32.63 ± 5.56 to 33.81 ± 6.73 (95% CI: 31.09-34.51). This difference was significant (F = 109.82, η²=0.80, P < 0.001). MCT also significantly improved medication adherence. In the experimental group, the mean score increased from 3.06 ± 1.88 to 7.81 ± 1.94 (95% CI: 7.38-8.64), whereas in the control group it changed from 3.50 ± 1.37 to 3.63 ± 1.54 (95% CI: 2.79-4.05). This difference was significant (F = 311.16, η²=0.92, P < 0.001). Conclusion Preliminary findings suggest that MCT may enhance both emotional and behavioral outcomes in GAD. If replicated in larger trials, its application in clinical practice could help mental health professionals address major challenges such as distress intolerance and poor medication adherence, potentially reducing patient distress and promoting long-term engagement in treatment. Iranian Registry of Clinical Trials (IRCT), IRCT20231128060213N1, registered on 05 January 2024 (retrospectively registered).

Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) predict poorer treatment outcomes. Available treatments for BPD and psychological trauma are often phase-based, first ensuring stabilization of dysregulated behaviors and emotions and later focusing on treating trauma. This study investigates the feasibility, acceptability, and preliminary efficacy of combining dialectical behavioral therapy group skills training (DBT-ST), consisting of mindfulness, emotion regulation, distress tolerance, and interpersonal-effectiveness skills, with eye movement desensitization and reprocessing (EMDR) individual therapy for patients with BPD and psychological trauma. Forty-two participants with BPD and psychological trauma (40 females, mean age = 28.5, SD = 9.2) participated in the study. All participants underwent an initial 6-month DBT-ST group (phase 1), then those randomized to the experimental group received EMDR, and those in the control condition continued DBT-ST (phase 2). Feasibility and acceptability were assessed through qualitative interviews. Additionally, borderline personality disorder symptoms and trauma-related symptoms were measured as secondary clinical outcomes. Assessments were conducted at baseline, post phase 1, and post phase 2. Overall retention from baseline to post phase 2 was 62%. Descriptively, retention was 81.2% in the DBT-ST continuation group and 72.2% in the DBT-ST+EMDR group, though this difference was not statistically significant. Qualitative interviews suggested that the sequential design was acceptable, and that DBT-ST helped some participants feel more prepared for subsequent trauma-focused work, although these findings are based on a small qualitative subsample. Both conditions reduced BPD symptoms, while only the DBT-ST+EMDR condition significantly reduced dissociative symptoms from baseline to post phase 2. A definitive, fully powered randomized clinical trial is warranted to confirm these findings and optimize the integration of DBT-ST and EMDR. Clinical Trials, NCT04856449. Registered on 08-04-2021.

Meta-analysis of associations between childhood emotional abuse and adulthood emotion regulation.

U.S. veterans experience chronic pain and physical and emotional stressors at a high rate. To inform intervention targets for chronic pain it is vital to understand the longitudinal associations of protective factors (e.g., distress tolerance and social support) with pain-related functioning among this population. This study assessed the longitudinal associations among distress tolerance (physical and emotional), social support, pain intensity, and pain-related disability in a sample of 345 U.S. post-9/11 combat veterans. Baseline and one-year follow-up assessments of self-reported pain intensity (numeric rating scale), pain-related disability (Pain Disability Inventory), physical and emotional distress tolerance (Distress Tolerance Inventory), pre- and post-deployment social support (Deployment Risk and Resilience Inventory), age, and education (in years) were collected (68.3% male, average age = 38.94 years [SD = 9.83]). Bayesian linear regression was used to predict pain intensity and pain-related disability at one year by age, education, pain intensity, social support, and physical and emotional distress tolerance reported at baseline. Results indicated baseline pain intensity, emotional (but not physical) distress tolerance, post-deployment social support, and age predicted follow-up pain-related disability (total R2 = 0.30, 95% CI: 0.21-0.39), while follow-up pain intensity was associated with baseline emotional distress tolerance only (R2 = 0.10, 95% CI: 0.05-0.16). These results suggest that emotional distress tolerance may be a promising target for intervention for both pain intensity and pain-related disability. Further, pain-related disability is impacted by a broader range of factors, including social support, and may therefore require a greater array of interventions than pain intensity.

The role of cravings in the association between distress tolerance and non-suicidal self-injury in adolescents.

The insula helps regulate affective distress and plays a critical role in maintaining tobacco use disorder. Task-based functional connectivity underlying cognitive performance during affective distress has previously distinguished between current smoking and long-term ex-smoking behavior. In the current study, we investigated whether individual differences in distress-related functional connectivity corresponded to short-term quit attempt outcomes. Participants performed a distress tolerance task while undergoing magnetic resonance imaging and planned a quit attempt a few days later. Participants completed five follow-up visits across 10 weeks to verify smoking status. Participants were then grouped based on quit outcomes (e.g., ≥ 7 consecutive days Abstained n = 13, ≥ 7 days Reduced cigarettes/day n = 18, or Smoked n = 27). In the right anterior insula and left posterior insula, there was a stepwise pattern of distress-related connectivity across groups (Abstained < Reduced < Smoked). The Smoked group had the strongest positive distress-related connectivity and this was associated with their negative mood and task accuracy. Stronger distress-related connectivity with the insula may represent increased cognitive-affective effort needed to tolerate distress during cognitive performance. The relationship across Abstained, Reduced, and Smoked groups suggests this measure of distress tolerance plays a role in the ability to quit smoking. This insula connectivity could be a modifiable target for neuromodulation to help reduce the cognitive-affective effort needed to refrain from smoking during stress-induced craving.

Novel evidence-based suicide-specific treatments are critical to addressing rising rates of suicide among veterans. To determine whether Project Life Force (PLF), a group intervention that augments suicide safety planning (SSP) with skills training, plus treatment as usual (TAU) delays or decreases suicidal behavior compared with TAU alone. This multisite randomized clinical trial, using intention-to-treat analyses, included veterans at high risk for suicide. Participants were recruited after psychiatric inpatient discharge or referral from 4 Veterans Health Administration outpatient care teams in hospitals in Pennsylvania, New York, and Texas between March 2018 and February 2024. Data were analyzed from April 2024 to October 2025. PLF is a manualized, 10- to 12-session (75-90 minutes per session) group intervention combining SSP with distress tolerance, emotion regulation, and interpersonal skills training. Sessions cover each of the 6 SSP steps, health management, reasons for living, SSP accessibility, and a recap, with up to 4 optional booster sessions offered. All participants received TAU, constituting individual SSP and standard outpatient mental health care. The primary outcome was time in days to first suicidal behavior (aborted, interrupted, or actual attempts or suicide death) over 12 months, assessed using the Columbia Suicide Severity Rating Scale and chart review. Secondary outcomes over 12 months included self-report measures of hopelessness, depression, treatment use, attitudes toward help-seeking, and suicide-related coping. A total of 207 participants (mean [SD] age, 46.1 [13.9] years; 178 male [86%]) were assessed at baseline and randomly assigned to PLF plus TAU (101 participants) or TAU alone (106 participants). Cox proportional hazards models showed no significant between-group difference in time to suicidal behavior; however, compared with TAU, PLF participants had a lower hazard of actual suicide attempts over 1 year (HR, 0.49; 95% CI, 0.26-0.92; P = .03). Secondary outcome analyses included data from 132 participants (64%) at posttreatment, 125 (60%) at month 6, and 130 (62%) at month 12. Treatment-by-time effects ranged from Cohen d = -0.03 to 0.35. Notably, PLF significantly improved suicide-related coping at posttreatment (estimate, 4.06; Cohen d, 0.21; P = .04) and month 6 (estimate, 5.36; Cohen d, 0.27; P = .007). No study-related adverse events occurred. In this randomized clinical trial of 207 participants, PLF plus TAU did not change time to suicidal behavior but did increase time to actual suicide attempts and improve suicide-related coping, thereby enhancing SSP impact. ClinicalTrials.gov Identifier: NCT03653637.

BackgroundEmergency health workers encounter critical decision-making challenges during mass-casualty incidents, where psychological factors-including distress tolerance, anxiety, and emotion regulation-may significantly influence triage effectiveness.ObjectiveThe aim of this study was to evaluate the decision-making skills of emergency health workers during triage in mass incidents and to examine the effects of distress tolerance, anxiety levels, and difficulties in emotion regulation on these skills.MethodsA descriptive and comparative study was conducted with 349 paramedics and emergency medical technicians working in pre-hospital emergency health services in Turkey. The Distress Tolerance Scale (SDS), Beck Anxiety Scale (BAS), Difficulties in Emotion Regulation Scale (DAS), and Triage Decision Making Inventory (TDDI) were used for data collection. Shapiro-Wilk test, Chi-square test, Wilcoxon test, and Kruskal-Wallis H test were applied in the study. Correlation analysis was conducted to determine relationships among scales.ResultsThe median values of Triage Decision Making Inventory, Difficulty in Emotion Regulation Scale, Beck Anxiety Scale, and Difficulty withstanding Distress Scale scores were , respectively. According to multiple regression analysis, triage decision-making skills were negatively affected by anxiety, positively affected by distress tolerance, and negatively affected by difficulties in emotion regulation (p < 0.05).ConclusionsIt was found that distress tolerance, emotion regulation, and self-efficacy positively influenced triage decision-making skills, while emotion dysregulation and anxiety negatively affected these skills. Factors such as experience, education level, type of triage training received, gender, marital status, and age also affected triage decision-making skills.

This study investigates the impact of a Dialectical Behavior Therapy (DBT)-based counseling program on emotional regulation (ER) and emotional eating (EE) among overweight female students. The program incorporated four core DBT modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. A sample of 68 female students at a public university in Saudi Arabia was selected for a quasi-experiment. The participants were divided equally into two groups: an experimental group (n = 34) and a control group (n = 34). The dependent variables (ER and EE) were assessed before and after the intervention (DBT-based counseling program). The experimental group outperformed the control group at the 0.01 level, which can be considered as preliminary evidence of an association between the DBT and enhanced ER and reduced EE. These findings suggest that the DBT-based program can help overweight students manage emotional distress and reduce reliance on food as a coping strategy during their transition from school to university. DBT-based counseling can be a preventive intervention for managing emotional distress and disordered eating patterns. DBT supports students' psychological well-being during critical transitional periods.

Introduction:Although acculturative stress contributes significantly to internalizing problems among Latinos who drink hazardously, the individual difference variables that strengthen or weaken this relationship have remained elusive. To address this gap, we examined two cognitive-affective factors, namely distress tolerance and emotion dysregulation, as candidate moderators. We expected that acculturative stress would be positively associated with internalizing problems (operationalized as anxious arousal, traumatic intrusions, and social anxiety) at lower levels of distress tolerance and/or higher levels of emotion dysregulation.Method:A sample of Latinos who drink hazardously (N = 99) completed measures of acculturative stress, distress tolerance, emotion dysregulation, and internalizing symptoms.Results:There was a significant acculturative stress × distress tolerance interaction explaining 5.02% and 4.19% of the variance in anxious arousal and traumatic intrusions, respectively. Acculturative stress was significantly positively associated with anxious arousal and traumatic intrusions only at lower levels of distress tolerance. There was also a significant acculturative stress × emotion dysregulation interaction explaining 7.46% of the variance in anxious arousal. Acculturative stress was significantly positively associated with anxious arousal only at higher levels of emotion dysregulation.Conclusion:Acculturative stress was associated with anxious arousal and traumatic intrusions among Latinos who drink hazardously with lower distress tolerance and/or higher emotion dysregulation. Enhancing distress tolerance and lowering emotion dysregulation may protect Latino individuals who engage in hazardous drinking and experience acculturative stress against internalizing problems, and these processes may serve as targets in future intervention programming.

The present study examined psychosocial predictors of hindrance to mindfulness, with a specific focus on fear of compassion, self-criticism, and distress tolerance. Mindfulness, although widely associated with psychological well-being, is often impeded by underlying cognitive and emotional vulnerabilities that remain underexplored, particularly in non-Western contexts. This study aimed to investigate how these psychosocial factors contribute to cognitive, emotional, and motivational hindrances to mindfulness. A correlational research design was employed. Data were collected from young adults (N = 610) aged 18 to 26 years, including both males and females, enrolled in Higher Education Commission (HEC)-recognized government, semi-government, and private educational institutions in Lahore, Pakistan. Participants were recruited using a purposive sampling strategy and included individuals from diverse academic disciplines who were proficient in Urdu and English. After data screening, a final sample of 444 participants was retained for analysis. Standardized measures included the Hindrances to Mindfulness Scale (HMS), Fear of Compassion Scale, Levels of Self-Criticism Scale, and Distress Tolerance Scale. Data were analyzed using SPSS-26. Pearson product–moment correlation was employed to examine relationships among variables, and hierarchical regression analyses were conducted to identify predictors. Results indicated that all study variables were significantly correlated at the 0.001 level. Hindrance to mindfulness dimensions (cognitive, emotional, and motivational) were positively associated with fear of compassion (for self, from others, and for others), self-criticism (comparative and internalized), and distress tolerance dimensions (tolerance, absorption, appraisal, and regulation). In Regression analyses, fear of compassion emerged as the strongest and most consistent predictor across all domains of mindfulness hindrance. Distress tolerance, particularly emotional absorption, contributed additional explanatory power, whereas self-criticism showed limited and domain-specific effects. The final models explained between 29.1% and 42.3% of the variance in hindrance to mindfulness. These findings underscore the central role of compassion-related fears and emotional regulation difficulties in obstructing mindfulness processes. The study highlights the importance of integrating compassion-focused and distress tolerance-based interventions to address barriers to mindfulness, with implications for culturally sensitive clinical practice and mental health interventions.

Purpose: This study aimed to investigate the reciprocal relationship between endometriosis-related pain and the consumption of cannabinoids and opioids. Additionally, this study explores whether pain-related anxiety acts as a mediator in this relationship by adopting a transactional model of adaptation to endometriosis. Methods: This cross-sectional study included 334 adult women diagnosed with endometriosis. An online questionnaire, distributed through social networks and patient associations, gathered data on pain intensity, substance use (cannabis, CBD, and opioids), pain-related anxiety, distress tolerance, and anxiety sensitivity. Results: Descriptive statistics revealed that 74.25% of participants reported using at least one substance. Pain was positively correlated with the severity level of CBD, opioid use, and pain-related anxiety. The severity level of cannabis uses negatively correlated with distress tolerance. Path modeling demonstrated that substance use predicted pain intensity, and that pain intensity is associated with pain-related anxiety, subsequently influencing substance use. The model suggests a transactional relationship between pain, pain-related anxiety, and substance use. Conclusions: These findings underscore the need for tailored therapeutic approaches for women with endometriosis. Substance use is associated with increased pain intensity, indicating a complex interplay. This study highlights the importance of considering psychosocial factors such as pain-related anxiety in understanding the relationship between substance use and pain in endometriosis. A comprehensive approach to care involving both medical and psychological perspectives is essential. Further studies are also required.

Temporal Precedence of Distress Tolerance in Predicting Anxiety and Depression: A Daily Diary Approach During Mindfulness-Based Intervention.

Acute effects of inpatient brief cognitive-behavioral therapy for suicide prevention on non-suicidal self-injury: Exploring the association with improved distress tolerance.

Existential, spiritual, and religious themes often evoke strong emotions in therapy, yet little is known about how clients’ emotion regulation relates to these aspects. Spiritual psychotherapy for inpatient residential and intensive treatment (SPIRIT) integrates meaning in life within a cognitive-behavioral treatment (CBT) framework in acute and intensive mental health care and provides an appropriate context for examining this. This qualitative study explores: (1) clients’ beliefs about expressing, managing, or suppressing emotions related to meaning in life, spirituality, or religion (MSR); (2) how emotion regulation strategies (e.g., reappraisal, acceptance, and distress tolerance) are influenced by addressing MSR in therapy; and (3) whether engaging with MSR activates emotion regulation mechanisms for clients’ experienced distress. We analyzed 118 client evaluation forms and 19 semi-structured client interviews using a thematic approach informed by emotion regulation theory. SPIRIT-CBT made implicit beliefs about (MSR-related) emotion regulation explicit, and group interactions sometimes led to changes. Clients showed various regulation strategies, for example: MSR-based reappraisal, connectedness, reflection, and positive refocusing. However, emotional tension and suppression were also reported. Particularly from the interviews, it emerged that the therapy facilitated regulation mechanisms, including narrative processing, perspective shifting, sense-making, and social belonging. Focusing on MSR and existential themes addresses an important gap in mental health care and may contribute to supporting clients’ emotional recovery and overall well-being.

Parenting styles have considerably changed over the past 20 years, with growing acceptance of neurodiverse traits in children. Attention deficit hyperactivity disorder, autism spectrum disorder, and other neurodevelopmental disorders are viewed as conditions that interfere with daily living, instead of being pathological issues. However, despite the acceptance of these conditions as a whole, there is also an increase in the manifestations of symptoms of the disorders with the absence of a diagnosis, thus shedding light on neurodevelopmental profiles may and modern parenting may interact. Specifically, how raising parental stress, autonomy management, and overparenting may lead to a child's behavioral and emotional reactions. It is important to note that correlation is not causation; in that this paper makes a case that parenting practices may not cause neurodivergence; however, it shapes a child's symptom expression and distress tolerance capabilities. This paper is founded on psychopathology, neurodiverse framework, and family systems theory. Additionally, the author advocates for the need to build parenting awareness that lower stress, expand flexible parenting according to the behavioral and emotional issues from a neurodevelopmental perspective.