Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Jun 1.
Published in final edited form as: Mindfulness (N Y). 2020 Apr 21;11(6):1460–1468. doi: 10.1007/s12671-020-01362-1

Acting with awareness and distress tolerance relate to PTSD symptoms among women with substance use disorder

Inna Arnaudova a,*, Hortensia Amaro b
PMCID: PMC7363041  NIHMSID: NIHMS1586249  PMID: 32670430

Abstract

Objectives:

Women with a history of trauma exposure and substance use disorder (SUD) are more likely to report co-occurring post-traumatic stress disorder (PTSD) symptoms than the general population. However, cognitive factors such as increased distress tolerance and mindfulness disposition might be especially protective against PTSD symptoms for women with SUD.

Methods:

We examined the associations of distress tolerance and mindfulness disposition as potential resilience factors to PTSD symptoms in a sample of women receiving residential treatment for SUD (N = 237, MAGE = 32.34, 56.96% Hispanic). PTSD symptoms were divided into the clusters of Reexperiencing, Avoidance, Dysphoria and Arousal.

Results:

Regression models revealed that distress tolerance and the mindfulness facet of acting with awareness are negatively and incrementally associated with total, dysphoria and arousal PTSD symptom severity, while non-reactivity has a significant negative relationship with avoidance PTSD symptoms. Only distress tolerance emerged to be negatively related to PTSD reexperiencing symptom severity.

Conclusions:

Our findings show that the ability to tolerate distress, as well as specific mindfulness skills, might protect against specific severe PTSD symptoms among women with SUD. Future research should examine whether targeting both of these facets is necessary for achieving favorable clinical outcomes on PTSD in this population.

Keywords: mindfulness, distress tolerance, substance use disorder, posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) often co-occur (e.g., Goldstein et al., 2016) and each disorder increases the risk for an individual to develop the other, especially among women (Berenz et al., 2017). Prevalence of PTSD, specifically, is also close to two times higher among women than men (e.g., Lehavot et al., 2018). This makes PTSD in the context of SUD an important issue for women’s mental health.

Common underlying mechanisms of PTSD and SUD might explain the high rate of symptom co-occurrence. Deficits in distress tolerance (i.e., affective non-reactivity to aversive experiences; Simons & Gaher, 2005) have been proposed to play a role in the etiology and maintenance of both disorders (e.g., Khantzian, 1997, Vujanovic, Litz & Farris, 2015). High mindfulness disposition (covering nonjudgmental attending, responding with awareness and acceptance to both internal and external signals, regardless of their affective load, e.g., Baer et al., 2006; Bishop et al., 2004), on the other hand, might serve as a resilience factor (e.g., Karyadi, VanderVeen, & Cyders, 2014; Vujanovic, Niles & Abrams, 2016). Although distress tolerance and mindfulness disposition might be related (Naragon-Gainey, McMahon & Chacko, 2017), they are usually studied separately, which creates uncertainty regarding which is more relevant for PTSD symptoms among women with SUD. It is important to examine the relative contribution of these factors to PTSD symptom severity, as they might serve as potential targets for both prevention and treatment of PTSD among women with SUD.

Experiencing, witnessing, or otherwise being exposed to a traumatic event, such as a close relative’s sudden death, does not alone cause PTSD. For example, high distress tolerance might protect against the development of PTSD symptoms following a traumatic event (Vujanovic, Litz & Farris, 2015) because of the ability to experience and manage the event-associated distress without becoming overwhelmed, rather than avoiding any reminders of the trauma, which might exacerbate PTSD (e.g., Ehlers & Clark, 2000). One essential form of distress tolerance (Leyro, Zvolensky & Bernstein, 2010) refers to the individual capacity to experience aversive emotions without it being an unsurmountable challenge and can be measured with the Distress Tolerance Scale (DTS, Simons & Gaher, 2005). Cross-sectional studies have shown that such distress tolerance is linked to reduced PTSD symptoms among individuals with a history of exposure to traumatic events (e.g., Vujanovic et al., 2011; Vujanovic, Marshall-Berenz, & Zvolensky, 2011), cocaine-dependent individuals (Vujanovic et al., 2016), and psychiatric inpatients with high frequency of diagnosed SUD (Vujanovic, Dutcher & Berenz, 2017). Last, changes in distress tolerance scores were related to lower PTSD symptoms at treatment completion among predominantly male veterans in residential treatment for PTSD (Banducci et al., 2017). Therefore, distress tolerance might be a potential target for treatment among individuals with both PTSD and SUD symptoms.

Although distress tolerance refers to affective non-reactivity to aversive experiences (Simons & Gaher, 2005), mindfulness disposition is a multidimensional construct (e.g., Baer et al., 2006; Bishop et al., 2004). Therefore, the emotion regulation skills covered by the mindfulness concept might additionally buffer the effects of trauma (Vujanovic, Niles & Abrams, 2016). We are aware of only three studies (Bowen et al., 2017; Garland & Roberts-Lewis, 2013; Shorey et al., 2014) that have examined the relationship of mindfulness and PTSD symptoms in samples with trauma exposure and clinically diagnosed SUD. Cumulative findings point toward a significant inverse relationship between PTSD symptom severity and mindfulness disposition, after statistically controlling for confounders.

Some studies use a composite mindfulness score in their analyses, which obstructs our ability to identify which mindfulness subfactor contributes most to PTSD symptoms. Few studies have examined specific mindfulness dimensions and their relationship to PTSD in SUD samples. Bowen and colleagues (2017), for example, tested the individual facets of mindfulness assessed by the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006). Acting with awareness, describing, and nonjudgmental acceptance were significantly associated with both PTSD and SUD symptom severity, whereas observing and non-reactivity were not. In their correlational analyses, Garland and Roberts-Lewis (2013) found all but the observing facet to have a negative relationship with PTSD symptom severity. Further research is needed to elucidate which key aspects of mindfulness are associated with reduced PTSD symptoms among women with SUD.

The relationship between distress tolerance and mindfulness is theoretically underspecified. Therefore, before distinguishing their specific contribution to PTSD symptoms among SUD samples, it is important to determine the magnitude of their overlap. A recent meta-analysis found a moderate correlation between distress tolerance and mindfulness across five samples (r = .38, Naragon-Gainey, McMahon & Chacko, 2017). Because mindfulness is an umbrella term for distinct patterns of relating to emotional, sensory, and experiential events (Baer et al., 2006), various aspects of mindfulness might have distinct relationships with distress tolerance in samples with SUD symptoms. Among smokers, only the mindfulness factors of acting with awareness and nonjudgment acceptance mindfulness factors were associated with distress tolerance after controlling for covariates (e.g., Luberto et al., 2014), whereas in a sample of heavy-drinking students, the facets of describing, nonjudgmental acceptance, and non-reactivity all emerged as significantly related to distress tolerance scores (Kraemer et al., 2017). Neither of these two studies reported a significant association between the observing facet and measures of distress tolerance. We are aware of only one study that has examined the association between those two concepts in an SUD sample (Hsu et al., 2013). The study found significant positive correlations between all five mindfulness facets and distress tolerance scores, with non-reactivity (r = .47) having the strongest relationship. These correlations are not high enough to preclude the simultaneous evaluation of the cognitive factors in cross-sectional studies on PTSD symptom severity.

Answering the question of whether mindfulness facets and distress tolerance uniquely contribute to PTSD resilience or largely overlap can help consolidate scientific efforts, uncover which cognitive mechanisms are of vital importance, and reduce redundancy in the literature on emotion regulation in PTSD, which mirrors the overabundance of overlapping constructs in the general emotional regulation literature (e.g., Naragon-Gainey, McMahon & Chacko, 2017). The importance of this question lies also in the need for future clinical interventions for individuals with SUD and PTSD to have a targeted approach towards the mechanisms associated with the biggest clinical change (NIMH, 2013), rather than relying on non-specific therapeutic effects.

Women might face distinct challenges when it comes to risk factors for PTSD, that go beyond trauma exposure (e.g., Pineles, Hall & Rasmusson, 2017). Studies that specifically investigate relationships between cognitive factors among women with SUD can bring us a step closer to understanding what underlies the increased PTSD vulnerability of women (Pineles, Hall & Rasmusson, 2017). To understand how distress tolerance and mindfulness facets relate to symptoms of PTSD among women with SUD, we examined whether: (a) distress tolerance is negatively associated with reduced severity by PTSD symptoms cluster, in replication of Vujanovic and colleagues (2016), and (b) facets of mindfulness have a significant negative association with PTSD symptoms beyond distress tolerance.

Methods

Participants

Baseline data collected for a randomized clinical trial (Amaro & Black, 2017) of Moment-by-Moment in Women’s Recovery (Vallejo & Amaro, 2009), a mindfulness-based relapse prevention adjunctive intervention program for women (N = 245) in gender-specific residential SUD treatment, were used for the present study. Participants were recruited at treatment entry. Eligibility criteria for the parent study were as follows: age in the range of 18–65, SUD diagnosis, ability to provide consent, and willingness to be audio recorded and provide broad consent for other studies using the collected data. Exclusion criteria included conditions interfering with the experimental treatment (i.e., suicidal ideation in the last 30 days, untreated psychotic disorder, or other chronic mental health problem), being currently imprisoned, or advanced pregnancy (see Amaro & Black, 2017 for full study methods description).

For this study, we additionally excluded women (n = 8) who did not endorse exposure to a traumatic event covered by Criterion A for PTSD diagnosis from the Diagnostic and Statistical Manual of Mental Disorders - 5th edition (DSM-V, American Psychiatric Association, 2013). Demographic, psychosocial and clinical characteristics of the present sample (N = 237, mean age = 32.34, 95% CI = [31.20, 33.49]) are reported in Table 1 and Table 2. Sixty-five women (27.42%) were diagnosed by the clinical team with PTSD according to the fourth (27%, APA, 2000) or fifth edition (70.89%, APA, 2013) of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and 41.35% of the sample had at least one additional mental health diagnosis to SUD and PTSD.

Table 1.

Sample characteristics (N = 237)

Characteristic n (%)
Ethnoracial group
 Non-Hispanic White 48 (20.25)
 Non-Hispanic Black 50 (21.10)
 Hispanic 135 (56.96)
 Other 4 (1.69)
Marital status
 Married or common law 17 (7.17)
 Separated, divorced, or widowed 45 (18.99)
 Never married 175 (73.84)
Education
 Less than high school 115 (48.52)
 High school or equivalent 64 (27.00)
 Some postsecondary education 58 (24.47)
Employment in 8 months prior to treatment entry
 Full-time 32 (13.50)
 Part-time 29 (12.24)
 Not working 176 (74.26)
Mandated to treatment
 Criminal justice 112 (47.26)
 Department of Children and Family Services 76 (32.07)
 Not mandated 49 (20.68)
SUD diagnosisa
 Alcohol use disorder (AUD) 24 (10.12)
 Drug use disorder (DUD) 175 (73.84)
 AUD and DUD 33 (13.92)
Top 5 substances used in 8 months prior to treatment entryb
 (Meth)amphetamines 182 (76.79)
 Marijuana 133 (56.12)
 Alcohol to intoxication 121 (51.05)
 Alcohol 88 (37.13)
 Cocaine 33 (13.92)
Top 5 life traumas reportedc
 Observed physical violence in childhood 148 (62.44)
 Physical abuse 147 (62.03)
 Death of a close person 142 (59.92)
 Experience stalking or threats 137 (57.81)
 Witnessed a physical attack 122 (51.48)
Open in a new tab
a

Some individuals (n = 5) did not receive a formal diagnosis.

b

Some individuals (n = 127) reported using more than one type of drug on the same day.

c

Most individuals (n = 221) endorsed more than one type of traumatic events.

Table 2.

Matrix of bivariate Pearson’s correlations between variables entered in the models, as well as descriptive results (N = 237)

Variable 1 2 3 4 5 6 7 8 9 10 11 12
 1. Trauma types −.13 .10 .01 −.08 −.12 −.05 .38 .34 .30 .29 .38
 2. Distress tolerance .15 .45 .47 .31 .25 −.31 −.29 −.49 −.31 −.44
 3. Observing .40 .12 −.19 .53 .06 .00 −.05 −.01 .00
 4. Describing .48 .23 .35 −.15 −.24 −.34 −.14 −.28
 5. Acting with awareness .46 .05 −.22 −.27 −.46 −.26 −.38
 6. Nonjudgmental acceptance −.17 −.13 −.20 −.21 −.05 −.19
 7. Non-reactivity −.12 −.20 −.21 −.18 −.20
 8. PTSD Reexperiencing .73 .66 .57 .88
 9. PTSD Avoidance .65 .45 .80
 10. PTSD Dysphoria .65 .92
 11. PTSD Arousal .74
 12. PTSD Total
Mean 5.87 44.12 13.80 16.50 16.78 14.60 14.99 5.47 2.04 8.43 1.97 17.89
Lower 95% CI 5.48 42.39 13.29 15.94 16.18 14.03 14.49 4.88 1.77 7.65 1.72 16.26
Upper 95% CI 6.27 45.85 14.31 17.06 17.39 15.17 15.50 6.05 2.30 9.22 2.23 19.52
Open in a new tab

Note. Correlation coefficients with Holm adjusted for multiple tests p-values < .05 are in bold. All bivariate correlations for re-experiencing symptoms had a sample size of 236, due to missing responses from one participant. Distress tolerance was measured with the Distress Tolerance Scale (Simons & Gaher, 2005). Observing, describing, acting with awareness, nonjudgmental acceptance and non-reactivity were assessed with the short Five-Facet Mindfulness Questionnaire (Bohlmeijer et al., 2011). PTSD symptoms were evaluated through the PTSD Symptom Scale – Self-Report for DSM-IV (Foa et al., 1997).

Procedure

For the current study, we used data from clinical records and selected measures administered during a baseline structured interview prior to randomization and intervention delivery for the parent randomized clinical trial. Data were recorded with REDCap (Harris et al., 2009). All parent study procedures were approved by the affiliated university’s institutional review board.

Measures

PTSD symptom severity in the last 30 days was assessed with the PTSD Symptom Scale – Self-Report for DSM-IV (Foa et al., 1997). The scale measures severity of PTSD symptoms on a 4-point Likert scale, ranging from not at all (0) to almost always (3). Participants responded to the items relative to any traumatic event experienced, not a specific traumatic event as traditional instructions recommend. Based on the factor analyses first proposed by Simms et al. (2002), and later validated by multiple groups (e.g., Boelen, van den Hout & van den Bout, 2008), we calculated scores for four different symptom clusters: Reexperiencing (5 items), Avoidance (2 items), Dysphoria (8 items) and Arousal (2 items). Summing all scores represents total PTSD symptom severity. All subscales showed high psychometric properties (Cronbach’s alphas > .86 and McDonald’s ⍵t > .90 for PTSD reexperiencing, dysphoria and Total; Spearman-Brown coefficients > .78 for PTSD avoidance and arousal).

Distress tolerance was measured by the Distress Tolerance Scale (DTS, Simons & Gaher, 2005), a 15-item self-report questionnaire containing items related to attitudes and responses during experiences of distress. Participants rated the items on a scale ranging from strongly agree (1) to strongly disagree (5). The total score was used as measure of distress tolerance, in accordance with Vujanovic et al. (2016). Cronbach’s alpha of DTS in the present sample was .88 and the McDonald’s omega total equaled .92.

Dispositional mindfulness was measured using the short 24-item version of the FFMQ (Bohlmeijer et al., 2011), which assesses an individual’s tendency to be mindful in everyday life. Items are rated on a 5-point Likert scale, ranging never true (1) to very often true (5). It provides scores for the following mindfulness dimensions: observing (4 items), describing (5 items), acting with awareness (5 item), nonjudgmental acceptance (5 items), and non-reactivity (5 items). All subscales had adequate internal consistency in this sample (Cronbach’s alphas: observing = .73, describing = .73, acting with awareness = .81, nonjudgmental acceptance = .74, non-reactivity = .66, McDonald’s omega total: observing = .74, describing = .82, acting with awareness = .85, nonjudgmental acceptance = .80, non-reactivity = .72).

Number of trauma types endorsed was measured as the sum of event types endorsed in the modified Life Stressors Checklist – Revised (LSC-R, Wolfe & Kimerling, 1997), that meet Criterion A of the diagnostic criteria for PTSD in DSM-V (APA, 2013).

Data Analyses

Data analyses procedures were modeled after those reported in Vujanovic et al. (2016). Binary associations between variables were assessed with Pearson’s correlations in order to determine the appropriateness of entering the independent variables simultaneously in subsequent models. P-values were adjusted for inflated family-wise error using Holm’s method.

PTSD total and symptom cluster scores were entered as criterion variables in five hierarchical linear regression models. In each model, the control variable of total trauma types was entered in Step 1, because more extensive trauma history has been linked to more severe PTSD (e.g., Johnson & Thompson, 2008). In Step 2, the first predictor of interest, DTS Sum, was entered. In Step 3, we added each of the facets of mindfulness to the model.

Missing values in this study were excluded in the calculation of summary variables. We applied Bonferroni correction for the number of regression models in the present paper (i.e., 5) and used alpha level of .01 to determine significance. Analyses were conducted using R (Version 3.5.1, R Core Team, 2017) in R Studio (Version 1.0.143 for Macintosh, R Studio Team, 2016).

Results

Binary Associations between Variables of Interest

The bivariate correlations and descriptive statistics of study variables can be found in Table 2. The facet of observing was not significantly correlated with any PTSD scores, therefore not considered in subsequent analyses.

Relationships between DTS, FFMQ, and PTSD Clustered Symptoms

We examined the relationships between distress tolerance and dispositional mindfulness and each of the measured PTSD symptom clusters (re-experience, avoidance, dysphoria and arousal), as well as PTSD total, in separate analyses. When examining PTSD re-experiencing symptom severity, adding distress tolerance scores to the model increased the variance explained by the overall model at both Step 2 (ΔR2 = .07, F(1, 233) = 20.35, p < .001) and Step 3. Adding the mindfulness facets did not improve the model at Step 3. The largest percentage of the variance was explained number of trauma types endorsed (R2 = .14, F(1, 234) = 38.69, p < .001).

Similarly, when adding distress tolerance scores in Step 2, the variance of PTSD avoidance symptom severity explained by the model increased significantly ( R2 = .06, F(1, 234) = 16.92, p < .001). Step 1 explained some of the variance of PTSD avoidance symptoms (R2 = .12, F(1, 235) = 31.46, p < .001). Last, Step 3 variables improved the model significantly. nonreactivity emerged as an additional significant independent variable, above and beyond distress tolerance.

Analyses of the dysphoria symptom cluster showed that distress tolerance scores improved the model significantly (ΔR2 = .20, F(1, 234) = 68.22, p < .001) over the variance explained by number of trauma types endorsed (R2 = .09, F(1, 235) = 23.79, p < .001). At Step 3, both acting with awareness and distress tolerance were significantly related to dysphoria severity.

Number of endorsed trauma types explained some of the variance of PTSD arousal symptom severity (R2 = .09, F(1, 235) = 21.97, p < .001). Distress tolerance scores in Step 2 improved the model ( R2 = .07, F(1, 234) = 20.34, p < .001). In Step 3, significant negative associations were additionally found with acting with awareness and distress tolerance scores, however, the improvement of the overall model was minimal between Step 2 and Step 3 (ΔR2 = .04, F(1, 230) = 3.13, p = .016).

Finally, a similar pattern emerged when using PTSD total scores as a criterion variable. When added, distress tolerance doubled the variance explained by the overall model (ΔR2 = .16, F(1, 234) = 52.08, p < .001, Step 1: R2 = .14, F(1, 235) = 39.5, p < .001). In Step 3, both distress tolerance and acting with awareness scores were significantly negatively correlated with PTSD severity scores.

Discussion

The analyses reported suggest that both distress tolerance and acting with awareness may be specific resilience factors for some PTSD symptoms. Distress tolerance was significantly negatively association with PTSD severity in all models except the model for avoidance symptoms. Acting with awareness scores were negatively associated with total, dysphoria and arousal symptoms, while the mindfulness facet of nonreactivity was negatively associated with avoidance symptoms.

Distress tolerance seems to contribute to most models in this sample in replication of Vujanovic et al. (2016), even when mindfulness facets are added to the models. This supports theories which have highlighted distress intolerance as an underlying risk factor for PTSD (Vujanovic, Litz & Farris, 2015). Previous research has shown significant gender differences in distress tolerance, with women’s self-report being lower than that of men (e.g., Vujanovic, Dutcher & Berenz, 2017). To our knowledge, ours is the first study examining the contribution of distress tolerance to PTSD exclusively among women with SUD. DTS scores in the present study are similar to those reported by cocaine-dependent women in the Vujanovic et al. (2016) study (M = 42.92, SD = 12.82), which were significantly lower than those reported by the male participants in their study. Therefore, we echo the suggestion by Vujanovic, Litz and Farris (2015) and others that more studies need to examine gender differences in this cognitive factor and gender’s contribution to PTSD symptomatology and other psychopathology. Particularly, the present findings suggest that increasing distress tolerance should be evaluated as a specific target for women with SUD and PTSD.

In this study, mindfulness facets explained an additional 4% to 8% of the PTSD symptom variance in some models. Specifically, the facet of acting with awareness, referring to the ability of responding to action triggers with increased attention rather than habitually (Baer et al., 2006), stood out as important factor for the dysphoria and arousal PTSD symptoms clusters. Overall, the findings regarding the acting with awareness facet of mindfulness and PTSD have been mixed. This facet has shown significant negative association with PTSD symptoms among a sample in after care program for SUD (Bowen et al., 2017), adults with exposure to trauma (Vujanovic et al., 2009), individuals with past exposure to trauma receiving inpatient psychiatric treatment (Martin et al., 2018), soldiers following their deployment (Shipherd & Salters-Pedneault, 2018), and trauma-exposed online participants (Boughner et al., 2016), but not trauma-exposed students (Kalill, Treanor & Roemer, 2014), police officers (Chopko & Shwartz, 2013), and Dutch participants with PTSD (Schoorl et al., 2015). A recent study by Stephenson and colleagues (2017) further showed that increases in acting with awareness predicted a reduction of PTSD symptom severity among veterans who received mindfulness-based stress reduction. Although the findings of the present study suggest that acting with awareness might be the most important mindfulness facet among women with SUD and PTSD symptoms, the mixed findings across studies point toward the need for continued research on the topic. The heterogeneity of results might be due to many factors, such as the different characteristics of study samples (e.g., gender), severity of psychopathology, measurement tools and analytic methods employed, or the influence of other dispositional or demographic factors included in the analyses. Meta-analytic approaches might be utilized to uncover the true contribution of this specific mindfulness facet to explaining PTSD symptom variance. Further, the significant associations were observed with measures of the non-specific PTSD symptoms of dysphoria and arousal, rather than the most prominent PTSD symptom of reexperiencing. The model of arousal was also just minimally improved by adding the facets of mindfulness. Therefore, the importance of acting with awareness for PTSD among women with SUD should be studied further before being able to unequivocally conclude that increasing acting with awareness is a worthwhile intervention target among women with SUD and PTSD symptoms.

The non-reactivity scale reached significance in the model for avoidance. However, the non-reactivity subscale showed somewhat lower internal consistency in the present sample, and thus interpretation of these results should be done with caution. Future research should develop a scale that captures more accurately the aspect of remaining non-reactive to internal experiences among women with SUD. The mindfulness facets of describing and nonjudgmental acceptance did not emerge as significant in any of the models. Nevertheless, the present study highlights the importance of studying facets of mindfulness separately.

The findings reported here suggest that distress tolerance and acting with awareness need to receive further attention when examining PTSD symptom severity among women with SUD. It is interesting to highlight that while distress tolerance and acting with awareness scores had the strongest bivariate correlations, they contributed distinctly to PTSD symptom severity. Future research should unpack these findings and understand better both the convergent and divergent validity of the specific measures of distress tolerance and acting with awareness.

It is notable that in the current study we observed a significant negative correlation between distress tolerance measure and severity of the re-experiencing symptoms of PTSD in replication of previous results (Vujanovic et al., 2016). Arguably, intrusions, nightmares, and flashbacks are the most upsetting and impairing PTSD symptoms (e.g., Holmes, Brewin & Hennessy, 2004) and result from disturbed autobiographical memory processes of both encoding and recalling the traumatic event (Ehlers & Clark, 2000). Previous studies on PTSD symptomatology have found a significant relationship between some mindfulness facets (e.g., act aware and nonjudgment; Vujanovic et al., 2009) and PTSD re-experiencing severity. Usually in previous studies, participants reported PTSD symptoms regarding a specific past traumatic event, whereas participants in this study reported symptoms associated with any traumatic event in their life. This might explain the contradictory finding of the present study. Therefore, it is also not surprising that in our analyses the number of trauma types endorsed was found to be most closely related to PTSD re-experiencing symptom severity. Further, the women in our study reported high rates of exposure to stressors, and the cumulative effect of these events might obscure some effects of cognitive factors on the severity of involuntary distressing memory events. Last, women in the present sample were in the early stages of residential treatment, and thus they had only recently discontinued substance use. Based on the self-medication hypotheses, substances might be used for the purpose of ameliorating PTSD symptoms (e.g., Khantzian, 1997). Consequently, if substance use diminishes PTSD symptoms, use discontinuation might be related to perceived increases in PTSD and re-experiencing symptoms. Such increases might have obfuscated the effects of some protective cognitive factors.

Limitations and Future Research

The study presented here is not without limitations. First, this was a cross-sectional examination of the contribution of cognitive factors to PTSD symptomatology, which limited analyses to testing simple associations. Therefore, no temporal or causal relationships can be inferred from the present study. A next important step is to evaluate how these factors change during treatment and whether their changes serve as a working mechanism behind the efficacy of PTSD treatments, as evidenced in the Stephenson et al. (2017) study. An additional limitation for this study is that we relied on self-reported PTSD symptoms about traumatic events in general, rather than a clinical assessment of PTSD symptoms. Also, the study relied solely on self-report scales in this study and by using the same measurement method, this study might suffer from common method bias. While some suggestions exist in the literature (Podsakoff et al., 2003) about statistically correcting for this, these techniques might lead to faulty conclusions and are not recommended. Further, the scale we used to assess PTSD symptoms does not reflect the recognition of numbing symptoms as a separate symptom category, which occurred with the publishing of DSM-V (APA, 2013). Future research should use scales such as the PTSD Checklist for DSM-V (Weathers et al., 2013), where severity scores can be calculated for the DSM-V PTSD symptom clusters.

Additional research on the role of distress tolerance and acting with awareness is needed among women with SUD. It is crucial that successful prevention and treatment interventions for PTSD are developed for this population. Interventions specifically increasing distress tolerance and acting with awareness should be evaluated in the future. Although there is little evidence for the effectiveness of PTSD interventions not directly addressing trauma, positive findings about the benefit of mindfulness-based interventions for PTSD have started to emerge (e.g., Talkovsky & Lang, 2017). An important next step is to evaluate whether mindfulness-based interventions produce reductions in PTSD symptomatology through changes in distress tolerance and acting with awareness.

Table 3.

Step 3 of regression models (N = 237)

PTSD criterion variable Variable B [95% CIs] β t p
Reexperiencing Step 3 Statistics: R2 = .22, F(6, 229) = 10.72, p < .001
(n = 236) Constant 7.87 [4.49, 11.25] 4.58 .000
Trauma Types .50 [.32, .67] .34 5.69 .000
Distress tolerance −.07 [−.12, −.02] −.21 −2.97 .003
Describing −.00 [−.16, .15] −.00 −.04 .971
Acting with awareness −.09 [−.24, .05] −.10 −1.28 .200
Nonjudgmental acceptance .01 [−.13, .15] .01 .19 .853
Non-reactivity −.05 [−.20, .10] −.04 −.66 .512
Avoidance Step 3 Statistics: R2 = .23, F(6, 230) = 11.24, p < .001
Constant 4.62 [3.09, 6.14] 5.97 .000
Trauma Types .20 [.12, .28] .30 5.14 .000
Distress tolerance −.01 [−.04, .01] −.10 −1.38 .170
Describing −.03 [−.10, .04] −.07 −.93 .355
Acting with awareness −.05 [−.12, .01] −.12 −1.63 .103
Nonjudgmental acceptance −.04 [−.10, .02] −.09 −1.25 .215
Non-reactivity −.07 [−.14, −.01] −.14 −2.13 .034
Dysphoria Step 3 Statistics: R2 = .38, F(6, 230) = 23.09, p < .001
Constant 20.01 [15.95, 24.07] 9.71 .000
Trauma Types .48 [.27, .68] .24 4.56 .000
Distress tolerance −.13 [−.19, −.07] −.29 −4.55 .000
Describing .06 [−.25, .12] −.05 −.68 .496
Acting with awareness −.38 [−.56, −.21] −.30 −4.42 .000
Nonjudgmental acceptance .06 [−.11,.23] .04 .73 .469
Non-reactivity −.13 [−.32,.05] −.09 −1.46 .145
Arousal Step 3 Statistics: R2 = .20, F(6, 230) = 9.71, p < .001
Constant 3.50 [2.00, 5.00] 4.60 .000
Trauma Types .16 [.09, .24] .25 4.23 .000
Distress tolerance −.03 [−.05, −.01] −.21 −2.90 .004
Describing .03 [−.03, .10] .07 1.00 .318
Acting with awareness −.10 [−.16, −.03] −.23 −3.02 .003
Nonjudgmental acceptance .05 [.01, .11] .11 1.64 .102
Non-reactivity −.05 [−.12, .01] −.11 −1.61 .109
Total Step 3 Statistics: R2 = .35, F(6, 230) = 20.65, p < .001
Constant 36.05 [27.40, 44.70] 8.21 .000
Trauma Types 1.34 [.90, 1.76] .32 5.98 .000
Distress tolerance −.25 [−.37, −.13] −.27 −4.09 .000
Describing −.06 [−.45, .32] −.02 −.33 .744
Acting with awareness −.63 [−.99, −.26] −.23 −3.40 .001
Nonjudgmental acceptance .09 [−.27, .45] .03 .49 .623
Non-reactivity −.31 [−.69, .08] −.10 −1.57 .118
Open in a new tab

Note. Scores of significant independent variables (p < .05) are in bold for emphasis. One participant did not respond to any items pertaining to the reexperiencing cluster. Measurement scales used Distress Tolerance Scale (Simons & Gaher, 2005), Five-Facet Mindfulness Questionnaire (Bohlmeijer et al., 2011) and PTSD Symptom Scale – Self-Report for DSM-IV (Foa et al., 1997).

Acknowledgements:

Funding support provided by a grant from the National Institute on Drug Abuse (5R01DA038648 to H. Amaro and D. Black), cosponsored by the National Institute on Alcohol Abuse and Alcoholism. The ideas and opinions expressed herein are those of the authors and endorsement of those opinions by funders is not intended nor inferred. We thank all team members of the parent study for their contributions and are grateful for the hard work of key study staff members (Luz Rodriguez, Connie Valencia, Vanesa Sanchez, and Karen Poulus) and the collaborating study site (Prototypes Women’s Center). We appreciate our statistical discussions with Dr. Lei Duan and Dr. Tamika Gilreath, as well as Dr. David Black’s feedback on earlier versions of this manuscript. We further thank Eric Linberg for editorial support.

Footnotes

Conflict of interest statement: All authors declare they have no conflicts of interest.

Ethics statement: The Institutional Review Board of the University of Southern California approved all procedures of the parent study.

Informed consent statement: All study participants provided informed consent prior to participation in the parent study.

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

References

  1. Amaro H, & Black DS (2017). Moment-by-Moment in Women’s Recovery: Randomized controlled trial protocol to test the efficacy of a mindfulness-based intervention on treatment retention and relapse prevention among women in residential treatment for substance use disorder. Contemporary Clinical Trials, 62, 146–152. 10.1016/j.cct.2017.09.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed - TR). Washington, DC: Author. [Google Scholar]
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC: Author. [Google Scholar]
  4. Baer RA, Smith GT, Hopkins J, Krietemeyer J, & Toney L (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27–45. 10.1177/1073191105283504. [DOI] [PubMed] [Google Scholar]
  5. Banducci AN, Connolly KM, Vujanovic AA, Alvarez J, & Bonn-Miller MO (2017). The impact of changes in distress tolerance on PTSD symptom severity post-treatment among veterans in residential trauma treatment. Journal of Anxiety Disorders, 47, 99–105. 10.1016/j.janxdis.2017.01.004. [DOI] [PubMed] [Google Scholar]
  6. Berenz EC, Roberson-Nay R, Latendresse SJ, Mezuk B, Gardner CO, Amstadter AB, & York TP (2017). Posttraumatic stress disorder and alcohol dependence: Epidemiology and order of onset. Psychological Trauma: Theory, Research, Practice, and Policy, 9(4), 485–492. 10.1037/tra0000185. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, ... & Devins G (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230–241. 10.1093/clipsy.bph077. [DOI] [Google Scholar]
  8. Boelen PA, van den Hout MA, & van den Bout J (2008). The factor structure of posttraumatic stress disorder symptoms among bereaved individuals: A confirmatory factor analysis study. Journal of Anxiety Disorders, 22(8), 1377–1383. 10.1016/j.janxdis.2008.01.018 [DOI] [PubMed] [Google Scholar]
  9. Bohlmeijer E, Ten Klooster PM, Fledderus M, Veehof M, & Baer R (2011). Psychometric properties of the Five Facet Mindfulness Questionnaire in depressed adults and development of a short form. Assessment, 18(3), 308–320. 10.1177/1073191111408231. [DOI] [PubMed] [Google Scholar]
  10. Boughner E, Thornley E, Kharlas D, & Frewen P (2016). Mindfulness-related traits partially mediate the association between lifetime and childhood trauma exposure and PTSD and dissociative symptoms in a community sample assessed online. Mindfulness, 7(3), 672–679. 10.1007/s12671-016-0502-3. [DOI] [Google Scholar]
  11. Bowen S, De Boer D, & Bergman AL (2017). The role of mindfulness as approach-based coping in the PTSD-substance abuse cycle. Addictive Behaviors, 64, 212–216. 10.1016/j.addbeh.2016.08.043. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Chopko BA, & Schwartz RC (2013). The relation between mindfulness and posttraumatic stress symptoms among police officers. Journal of Loss and Trauma, 18(1), 1–9. 10.1080/15325024.2012.674442. [DOI] [Google Scholar]
  13. Ehlers A, & Clark DM (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319–345. 10.1016/S0005-7967(99)00123-0. [DOI] [PubMed] [Google Scholar]
  14. Foa E, Cashman L, Jaycox L, & Perry K (1997). The validation of a self-report measure of PTSD: The Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445–451. 10.1037/1040-3590.9.4.445. [DOI] [Google Scholar]
  15. Garland EL, & Roberts-Lewis A (2013). Differential roles of thought suppression and dispositional mindfulness in posttraumatic stress symptoms and craving. Addictive Behaviors, 38(2), 1555–1562. 10.1016/j.addbeh.2012.02.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Goldstein RB, Smith SM, Chou SP, Saha TD, Jung J, Zhang H, ... & Grant BF (2016). The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Social Psychiatry and Psychiatric Epidemiology, 51(8), 1137–1148. 10.1007/s00127-016-1208-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, & Conde JG (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. 10.1016/j.jbi.2008.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Holmes EA, Brewin CR, & Hennessy RG (2004). Trauma films, information processing, and intrusive memory development. Journal of Experimental Psychology: General, 133(1), 3–22. 10.1037/0096-3445.133.1.3. [DOI] [PubMed] [Google Scholar]
  19. Hsu SH, Collins SE, & Marlatt GA (2013). Examining psychometric properties of distress tolerance and its moderation of mindfulness-based relapse prevention effects on alcohol and other drug use outcomes. Addictive Behaviors, 38(3), 1852–1858. 10.1016/j.addbeh.2012.11.002. [DOI] [PubMed] [Google Scholar]
  20. Johnson H, & Thompson A (2008). The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review. Clinical Psychology Review, 28(1), 36–47. 10.1016/j.cpr.2007.01.017. [DOI] [PubMed] [Google Scholar]
  21. Kalill KS, Treanor M, & Roemer L (2014). The importance of non-reactivity to posttraumatic stress symptoms: A case for mindfulness. Mindfulness, 5(3), 314–321. 10.1007/s12671-012-0182-6. [DOI] [Google Scholar]
  22. Karyadi KA, VanderVeen JD, & Cyders MA (2014). A meta-analysis of the relationship between trait mindfulness and substance use behaviors. Drug and Alcohol Dependence, 143, 1–10. 10.1016/j.drugalcdep.2014.07.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Khantzian EJ (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231–244. 10.3109/10673229709030550. [DOI] [PubMed] [Google Scholar]
  24. Kraemer KM, O’Bryan EM, Johnson AL, & McLeish AC (2017). The role of mindfulness skills in terms of anxiety-related cognitive risk factors among college students with problematic alcohol use. Substance Abuse, 38(3), 337–343. 10.1080/08897077.2017.1340394. [DOI] [PubMed] [Google Scholar]
  25. Lehavot K, Katon JG, Chen JA, Fortney JC, & Simpson TL (2018). Post-traumatic stress disorder by gender and veteran status. American Journal of Preventive Medicine, 54(1), e1–e9. 10.1016/j.amepre.2017.09.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Leyro TM, Zvolensky MJ, & Bernstein A (2010). Distress tolerance and psychopathological symptoms and disorders: A review of the empirical literature among adults. Psychological Bulletin, 136(4), 576–600. 10.1037/a0019712. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Luberto CM, McLeish AC, Robertson SA, Avallone KM, Kraemer KM, & Jeffries ER (2014). The role of mindfulness skills in terms of distress tolerance: A pilot test among adult daily smokers. American Journal on Addictions, 23(2), 184–188. 10.1111/j.1521-0391.2013.12096.x. [DOI] [PubMed] [Google Scholar]
  28. Martin CE, Bartlett BA, Reddy MK, Gonzalez A, & Vujanovic AA (2018). Associations between mindfulness facets and PTSD symptom severity in psychiatric inpatients. Mindfulness , 9, 1571–1583. 10.1007/s12671-018-0904-5. [DOI] [Google Scholar]
  29. Naragon-Gainey K, McMahon TP, & Chacko TP (2017). The structure of common emotion regulation strategies: A meta-analytic examination. Psychological Bulletin, 143(4), 384–427. 10.1037/bul0000093. [DOI] [PubMed] [Google Scholar]
  30. National Institute of Mental Health (NIMH). (2013). NIMH’s new focus in clinical trials. Retrieved on 19 May 2019 from https://www.nimh.nih.gov/funding/grant-writing-and-application-process/concept-clearances/2013/nimhs-new-focus-in-clinical-trials.shtml
  31. Pineles SL, Hall KAA, & Rasmusson AM (2017). Gender and PTSD: Different pathways to a similar phenotype. Current Opinion in Psychology, 14, 44–48. 10.1016/j.copsyc.2016.11.002. [DOI] [PubMed] [Google Scholar]
  32. Podsakoff PM, MacKenzie SB, Lee JY, and Podsakoff NP (2003). Common method biases in behavioral research: a critical review of the literature and recommended remedies. Journal of Applied Psychology, 88(5), 879–903. 10.1037/0021-9010.88.5.879 [DOI] [PubMed] [Google Scholar]
  33. R Core Team. (2017). R: A language and environment for statistical computing. Retrieved from https://www.R-project.org/.
  34. R Studio Team. (2016). R Studio: Integrated development for R. Retrieved from http://www.rstudio.com/.
  35. Schoorl M, Van Mil-Klinkenberg L, & Van Der Does W (2015). Mindfulness skills, anxiety sensitivity, and cognitive reactivity in patients with posttraumatic stress disorder. Mindfulness, 6(5), 1004–1011. 10.1007/s12671-014-0346-7. [DOI] [Google Scholar]
  36. Shipherd JC, & Salters-Pedneault K (2018). Do acceptance and mindfulness moderate the relationship between maladaptive beliefs and posttraumatic distress? Psychological Trauma, 10(1), 95–102. 10.1037/tra0000248. [DOI] [PubMed] [Google Scholar]
  37. Shorey RC, Brasfield H, Anderson S, & Stuart GL (2014). Differences in trait mindfulness across mental health symptoms among adults in substance use treatment. Substance Use & Misuse, 49(5), 595–600. 10.3109/10826084.2014.850310. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Simms LJ, Watson D, & Doebbelling BN (2002). Confirmatory factor analyses of posttraumatic stress symptoms in deployed and nondeployed veterans of the Gulf War. Journal of Abnormal Psychology, 111(4), 637–647. 10.1037/0021-843X.111.4.637 [DOI] [PubMed] [Google Scholar]
  39. Simons JS, & Gaher RM (2005). The Distress Tolerance Scale: Development and validation of a self-report measure. Motivation and Emotion, 29(2), 83–102. 10.1007/s11031-005-7955-3. [DOI] [Google Scholar]
  40. Stephenson KR, Simpson TL, Martinez ME, & Kearney DJ (2017). Changes in mindfulness and posttraumatic stress disorder symptoms among veterans enrolled in mindfulness-based stress reduction. Journal of Clinical Psychology, 73(3), 201–217. 10.1002/jclp.22323. [DOI] [PubMed] [Google Scholar]
  41. Talkovsky AM, & Lang AJ (2017). Meditation-based approaches in the treatment of PTSD. PTSD Research Quarterly, 28(2). [Google Scholar]
  42. Vallejo Z, & Amaro H (2009). Adaptation of mindfulness-based stress reduction program for addiction relapse prevention. The Humanistic Psychologist, 37(2), 192–206. 10.1080/08873260902892287. [DOI] [Google Scholar]
  43. Vujanovic AA, Bonn-Miller MO, Potter CM, Marshall EC, & Zvolensky MJ (2011). An evaluation of the relation between distress tolerance and posttraumatic stress within a trauma-exposed sample. Journal of Psychopathology and Behavioral Assessment, 33(1), 129–135. 10.1007/s10862-010-9209-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Vujanovic AA, Dutcher CD, & Berenz EC (2017). Multimodal examination of distress tolerance and posttraumatic stress disorder symptoms in acute-care psychiatric inpatients. Journal of Anxiety Disorders, 48, 45–53. 10.1016/j.janxdis.2016.08.005. [DOI] [PubMed] [Google Scholar]
  45. Vujanovic AA, Litz BT, & Farris SG (2015). Distress tolerance as risk and maintenance factor for PTSD: Empirical and clinical implications In Martin CR, Preedy VR, & Patel VB (Eds.), Comprehensive guide to post-traumatic stress disorder (pp. 1–13). Cham, Switzerland: Springer. [Google Scholar]
  46. Vujanovic AA, Marshall-Berenz EC, & Zvolensky MJ (2011). Posttraumatic stress and alcohol use motives: A test of the incremental and mediating role of distress tolerance. Journal of Cognitive Psychotherapy, 25(2), 130–141. 10.1891/0889-8391.25.2.130 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Vujanovic AA, Niles BL, & Abrams JL (2016) Mindfulness and meditation in the conceptualization and treatment of posttraumatic stress disorder In Shonin E, Gordon W, & Griffiths M (Eds.), Mindfulness and Buddhist-derived approaches in mental health and addiction (pp. 225–245). Cham, Switzerland: Springer. [Google Scholar]
  48. Vujanovic AA, Rathnayaka N, Amador CD, & Schmitz JM (2016). Distress tolerance: Associations with posttraumatic stress disorder symptoms among trauma-exposed, cocaine-dependent adults. Behavior Modification, 40(1–2), 120–143. 10.1177/0145445515621490. [DOI] [PubMed] [Google Scholar]
  49. Vujanovic AA, Youngwirth NE, Johnson KA, & Zvolensky MJ (2009). Mindfulness-based acceptance and posttraumatic stress symptoms among trauma-exposed adults without axis I psychopathology. Journal of Anxiety Disorders, 23(2), 297–303. 10.1016/j.janxdis.2008.08.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, & Schnurr PP (2013). The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at www.ptsd.va.gov. [Google Scholar]
  51. Wolfe J, & Kimerling R (1997). Gender issues in the assessment of posttraumatic stress disorder In Wilson J & Keane TM (Eds.), Assessing psychological trauma and PTSD (pp. 192–238). New York, NY: Guilford Press. [Google Scholar]

RESOURCES