Abstract
Background
The link between anxiety/fear and gut dysfunction has been robustly documented in both physical and mental health literatures. The current study explored distress tolerance as a potential mechanism in the relation between anxiety sensitivity and gut-specific anxiety.
Method
A cross-sectional sample of 828 adults completed measures of distress tolerance, gut-specific anxiety, and anxiety sensitivity. Multiple linear regression analyses were conducted to determine variable associations, including potential mediating factors.
Results
The results demonstrated a bidirectional relation between anxiety sensitivity and gut-specific anxiety (β = 0.23, p < 0.001; β = 0.22, p < 0.001). Findings suggest distress tolerance is a significant mediator that may partially explain the relation between gut-specific anxiety and anxiety sensitivity more broadly (β = 0.11, CI [0.07–0.14]). Mediation results were consistent when individual subscales of distress tolerance or anxiety sensitivity were incorporated.
Conclusion
The outcome of the present study merits additional examination of the psychosomatic nature of distress tolerance as a potential clinical target for individuals with both anxiety and gut-related disorders.
Keywords: Distress tolerance, Anxiety, Psychogastroenterology, Gut-specific anxiety, Health psychology
Introduction
Digestive diseases affect more than 60 million individuals in the USA, with an annual cost burden of over $141 billion [1]. Abdominal pain is the leading gastrointestinal complaint in outpatient visits, followed closely by diarrhea, constipation, vomiting, nausea, and heartburn or indigestion [2]. Such maladaptive digestive symptomatology has demonstrated associations with psychosocial factors such as anxiety, fear, depression, and stress [3–5]. While these aversive emotional experiences interact with biological factors in digestive diseases [3, 6], these relations are not yet well-understood.
Anxiety and Gastrointestinal Distress
Individuals with elevated anxiety1 have been shown to have exacerbated symptoms related to digestive disease [8]. On the other hand, anxiety and gut-specific anxiety often are comorbid results of functional [or other] gastrointestinal disorders [9, 10]. This distinct bidirectional relation between various types of anxiety and digestive dysfunction has been substantiated through interventional work, where it has been demonstrated that cognitive-behavioral therapy is effective in ameliorating both anxiety and negative digestive symptoms [11, 12].
Gut-specific anxiety has been defined as increased acuity and worry related to gastrointestinal sensations and symptoms [13]. Anxiety sensitivity, in contrast, is a more general preoccupation with the physiological symptoms of anxiety (including but not limited to physiological sensations in the gut), and the perception of such symptoms as harmful [14]. Many individuals with digestive diseases report significant symptoms of anxiety, and the association between general anxiety sensitivity and gut-specific anxiety (which is associated with gastrointestinal distress) has been previously demonstrated [13, 15]. Given that, at times, individuals with significant manifestations of anxiety also experience gastrointestinal dysfunction and/or gut-specific anxiety [16], these constructs do overlap. Some individuals, however, may experience elevated general anxiety sensitivity, with no such increase in gut-specific anxiety, and vice versa.
Anxiety sensitivity and gut-specific anxiety have been conceptualized as distinct constructs. In the development of the Visceral Sensitivity Index (VSI) [13], a validated measure of gut-specific anxiety, the anxiety sensitivity, and gut-specific anxiety variables were moderately correlated, but the VSI was a stronger predictor of irritable bowel symptoms (IBS) [13]. Additional studies indicate that IBS diagnostic status impacts the strength of the relation between gut-specific anxiety and anxiety sensitivity. This relation is stronger in individuals who have an IBS diagnosis, suggesting that there are individuals who do not experience overlap in anxiety sensitivity and gut-specific anxiety, therefore reinforcing that these constructs are often overlapping but inherently different [15]. From another perspective, gut-specific anxiety is a strong predictor of IBS diagnostic status, above and beyond anxiety sensitivity and other general worry [10].
Some behavioral or general psychological treatments targeted at overall anxiety symptoms have been effective in alleviating gut-based anxiety and, in turn, gastrointestinal dysfunction [17, 18]. What is lacking, however, is an understanding of the underlying mechanisms of these relations. Continuing to elucidate how overall anxiety and gut-specific anxiety are related may aid in the development of even more targeted and more effective treatments or reveal why current treatments are effective for only some individuals.
Distress Tolerance
Distress tolerance is the trait-like propensity for enduring uncomfortable or negative emotional states [19], and has been extensively studied in psychopathology, particularly within the area of substance use (e.g., smoking cessation, alcohol, and cannabis use) [20, 21]. Lower distress tolerance has been associated with higher rates of alcohol and cannabis use, as well as difficulty with smoking cessation attempts. Given these results, some researchers have begun to target distress tolerance as a potential mechanism in the treatment of substance use disorders with helpful results [22], thereby suggesting its potential as a mechanism in other diseases and conditions, as well. Indeed, some have suggested the role of certain latent constructs, such as distress tolerance, as broader etiological roots of several mental disorders [23].
Distress tolerance also has been studied across the broader anxiety literature [24]. In general, greater inability to tolerate discomfort or emotional distress (i.e., distress intolerance) is associated with greater anxiety symptomatology [25]. For instance, individuals with panic disorder may avoid certain situations due to their overall low tolerance or inability to endure distressing physical sensations [26]. It is possible that distress tolerance—the overall inability to cope with uncomfortable or negative emotional states—may underlie a number of maladies including those of gastrointestinal nature or leading to gut-specific anxiety, such as IBS or irritable bowel disease. This relation, however, requires additional investigation.
While anxiety and other psychological factors have been implicated in a large number of gastrointestinal disorders as exacerbating symptoms and possibly leading to dysfunction [11, 27, 28], research has yet to establish a direct link between distress tolerance and gut-specific anxiety. As aforementioned, however, some researchers propose that increased distress tolerance may include a capacity to tolerate unpleasant physiological sensations (e.g., gastrointestinal discomfort), as well as emotional states [29]. Additionally, though anxiety sensitivity has been shown to be associated with gut-specific anxiety [13, 15], the exact mechanisms involved in this relation and the nature of which individuals might be affected by one or both of these aversive states remain unknown.
Thus, the aim of the current study was to examine the potential mechanistic or underlying role of distress tolerance in the relation between anxiety sensitivity and gut-specific anxiety. To replicate prior work, it was first hypothesized that anxiety and gut-specific anxiety would be significantly associated. Second, it was predicted that distress tolerance would be a mediating factor in partially explaining or altering the relation between anxiety sensitivity and gut-specific anxiety. Finally, it was hypothesized that distress tolerance would be a common factor in predicting both anxiety and gut-specific anxiety.
Method
Participants and Procedures
An adult, cross-sectional, national sample (N = 826) from the USA was recruited online using Amazon Mechanical Turk (MTurk) as part of a larger project examining psychosocial factors in oral and overall health [30]. Participants were required to complete questionnaires in English, be 18 years or older, electronically sign a written consent form, and were not selected for any specific digestive or gastrointestinal condition. That is, anxiety and distress tolerance data were obtained from a general convenience sample of participants. MTurk participants are typically more liberal in their political ideologies, younger, and more educated [31] but have been shown to be a reliable source for large survey studies [31].
In addition to providing demographic data such as age, gender, income, and education, the participants completed a number of self-report measures of psychological states, including those outlined below. Additionally, several validity items were included in the data collection to guard against response bias related to the online nature of the study. Sample characteristics are displayed in Table 1. The project was approved by the authors’ Institutional Review Board.
Table 1.
Sample characteristics
| No. or mean | % or SD | ||
|---|---|---|---|
| Gender | Female | 488 | 58.9% |
| Male | 340 | 41.1% | |
| Age (years) | 48.0 | 12.7 | |
| Race/ethnicitya | White | 671 | 81.2% |
| Black/African | 75 | 9.1% | |
| American | |||
| Hispanic | 38 | 4.6% | |
| Asian | 46 | 5.6% | |
| Native American | 16 | 1.9% | |
| Other | 8 | 1.0% | |
| Education (years) | 15.4 | 2.6 | |
| Household income | Less than $10,000 | 34 | 4.1% |
| $10,000–$14,999 | 35 | 4.2% | |
| $15,000–$24,999 | 95 | 11.5% | |
| $25,000–$34,999 | 117 | 14.1% | |
| $35,000–$49,999 | 130 | 15.7% | |
| $50,000–$74,999 | 201 | 24.3% | |
| $75,000–$99,999 | 117 | 14.1% | |
| $100,000–$149,999 | 66 | 8.0% | |
| $150,000–$199,999 | 23 | 2.8% | |
| $200,000 or more | 10 | 1.2% | |
| Anxiety Sensitivity Index-3 | Total score | 20.9 | 16.0 |
| Physical concerns | 7.1 | 6.0 | |
| Cognitive concerns | 5.3 | 6.1 | |
| Social concerns | 8.5 | 5.7 | |
| Distress Tolerance Scale | Total score | 3.3 | 1.0 |
| Tolerance | 3.3 | 1.1 | |
| Absorption | 3.3 | 1.2 | |
| Appraisal | 3.3 | 1.0 | |
| Regulation | 3.1 | 1.1 | |
| Visceral Sensitivity Indexb | 38.9 | 21.4 |
Participants were allowed to select more than one race/ethnicity; thus, the percentages do not sum to 100%
VSI scores reversed for interpretability such that higher scores represent higher sensitivity
After eliminating data from participants who did not respond appropriately to all validity items (n = 205), two other participant’s data were dropped due to missing data, resulting in a sample of 826 participants
Measures
Anxiety The Anxiety Sensitivity Index-3 (ASI-3) [32] is a self-report assessment that targets a trait-like characteristic of anxiety that includes subscales about physiological, social, and cognitive concerns. Higher scores indicate greater anxiety sensitivity and can be depicted using a total score and/or three subscale scores. Example items include “It is important for me not to appear nervous” or “When I notice my heart skipping a beat, I worry that there is something seriously wrong with me.” Means and standard deviations for the ASI-3 total and subscale scores are displayed in Table 1. Prior work on the ASI-3 has provided evidence for good internal consistency, test-retest reliability, and overall construct validity [32].
Gut-Specific Anxiety
As a measure theoretically associated with gut dysfunction, the Visceral Sensitivity Index (VSI) [13] was administered. Participants were asked to rate their level of distress on a Likert-type scale from 1 (“strongly agree”) to 6 (“strongly disagree”) on 15 items such as “I worry that whenever I eat during the day, bloating and distension in my belly will get worse” or “When I enter a place I haven’t been before, one of the first things I do is look for a bathroom.” Scores were reversed for ease of interpretability such that greater scores would demonstrate greater gut-specific anxiety. The means and standard deviations of the total VSI scores also are displayed in Table 1. The VSI likewise has demonstrated evidence for good psychometric properties including reliability and construct validity [13, 15].
Distress Tolerance
The Distress Tolerance Scale (DTS) [19] was used to assess individual distress tolerance. The scale includes a total score in addition to four subscales (i.e., Tolerance, Absorption, Appraisal, and Regulation). Higher scores are indicative of greater self-reported abilities to tolerance distress. Example items include “My feelings of distress are so intense that they completely take over” and “I’ll do anything to stop feeling distressed or upset.” Prior work has demonstrated good psychometric evidence including internal consistency (alpha = 0.89) as well as validity [19].
Statistical Analyses
Pearson’s correlations and independent samples t tests were used to assess associations and differences among demographic as well as other study variables. To test the specific hypotheses, a multiple linear regressions approach was utilized. SPSS 25 was used in all data analyses including the PROCESS Macro [33] to facilitate mediation models. Due to the cross-sectional nature of the data and the previously discussed association between anxiety and gut-specific anxiety, multiple models were tested such that the independent and dependent variables were alternated to assume various directionalities. That is, in the first mediation model, anxiety sensitivity was the predicting variable and gut-specific anxiety the outcome. In the second mediation model, gut-specific anxiety was the predicting variable and anxiety sensitivity the outcome.
Gender, age of participant, income, and education were controlled for in all statistical models. Given the cross-sectional nature of the data and inability to infer any causal claims, special attention was paid to the amount of variance accounted for in each model (i.e., R2).
Results
Sample Characteristics
Overall descriptive statistics for the sample are displayed in Table 1. Anxiety sensitivity was positively correlated with visceral sensitivity (r = 0.36, p < .001) and negatively with distress tolerance (r = − 0.41, p < .001). Distress tolerance also was negatively associated with visceral sensitivity (r = − 0.38, p < .001). There were no significant gender differences in anxiety or visceral sensitivity, or distress tolerance. An increase in age was associated with less anxiety and visceral sensitivity, with greater tolerance for distress. Additionally, higher income was associated with less anxiety and greater tolerance for distress. Educational level was not significantly associated with any of the relevant variables. A correlation table is provided in Table 2, also including the subscale correlations with all other variables.
Table 2.
Correlations of study variables and subscales
| Gender | Age | Income | Education | ASI Total | VSI Total | DTS Total | ASI Phys | ASI Cog | ASI Soc | DTS Tol | DTS Abs | DTS App | DTS Reg | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Gender | 1.00 | |||||||||||||
| Age | −0.08* | 1.00 | ||||||||||||
| Income | 0.03 | 0.00 | 1.00 | |||||||||||
| Education | 0.06 | − 0.01 | 0.24** | 1.00 | ||||||||||
| ASI total | 0.06 | − 0.24** | − 0.10** | − 0.05 | 1.00 | |||||||||
| VSI total | 0.05 | − 0.17** | − 00.04 | 0.01 | 0.36** | 1.00 | ||||||||
| DTS total | 0.01 | 0.17** | 0.08* | 0.01 | − 0.41** | − 0.38** | 1.00 | |||||||
| ASI Phys | 0.01 | − 0.18** | − 0.12** | − 0.06 | 0.91** | 0.36** | − 0.37** | 1.00 | ||||||
| ASI Cog | .12** | − 0.26** | − .010** | − 0.04 | 0.91** | 0.34** | − 0.39** | 0.76** | 1.00 | |||||
| ASI Soc | 0.03 | − 0.22** | − 0.04 | − 0.02 | 0.89** | 0.28** | − 0.33** | 0.71** | 0.70** | 1.00 | ||||
| DTS Tol | 0.04 | 0.14** | 0.06 | 0.02 | − 0.36** | − 0.34** | 0.92** | − 0.33** | − 0.35** | − 0.28** | 1.00 | |||
| DTS Abs | 0.06 | 0.19** | 0.05 | − 0.02 | − 0.37** | − 0.35** | 0.92** | − 0.33** | − 0.36** | − 0.32** | 0.84** | 1.00 | ||
| DTS App | − 0.06 | 0.18** | 0.09* | − 0.01 | − 0.46** | − 0.39** | 0.91** | − 0.40** | − 0.46** | − 0.37** | 0.78** | 0.81** | 1.00 | |
| DTS Reg | − 0.02 | 0.09** | 0.10** | 0.06 | − 0.28** | − 0.29** | 0.84** | − 0.26** | − 0.25** | − 0.23** | 0.68** | 0.64** | 0.68** | 1.00 |
Correlation is significant at the 0.05 level (2-tailed)
Correlation is significant at the 0.01 level (2-tailed)
N = 826–828 depending on variable. For full mediation analyses, listwise deletion was used resulting in the n = 826. ASI-3 - Anxiety Sensitivity Index-3 total score, VSI - Visceral Sensitivity Index, DTS - Distress Tolerance Scale total score, ASI Phys - ASI Physical concerns, ASI Cog - ASI Cognitive concerns, ASI Soc - ASI Social concerns, DTS Tol - DTS Tolerance, DTS Abs - DTS Absorption, DTS App - DTS Appraisal, DTS Reg - DTS Regulation
Distress Tolerance as a Mediator
Initial regression results demonstrated that higher overall anxiety sensitivity was predictive of greater gut-specific anxiety (β = 0.23, p < 0.001). In addition, increased anxiety sensitivity was associated with less distress tolerance (β = − 0.39, p < 0.001). On the other hand, greater distress tolerance was predictive of less gut-specific anxiety (β = − 0.28, p < 0.001). Individual distress tolerance had an indirect effect, such that it significantly mediated the relation between anxiety and gut-specific anxiety (β = 0.11, CI [0.07–0.14]). Those with greater general anxiety sensitivity were more likely to have lower tolerance for uncomfortable or negative emotional states and thereby higher levels of gut-specific anxiety. The mediation models are depicted in Fig. 1. Similar models were conducted to examine individual subtypes of distress tolerance (i.e., Appraisal, Absorption, Tolerance, and Regulation) and their role as mediators and similar results were confirmed. Results of the mediation analyses are displayed in Table 3.
Fig. 1.
Path models of anxiety sensitivity predicting gut-specific anxiety (top panel) and vice versa (bottom panel), both with distress tolerance as a mediator. Top panel R2 = 0.20; bottom panel R2 = 0.25
Table 3.
Mediation model results with anxiety sensitivity as an outcome (top) and with anxiety sensitivity as an outcome (bottom). Distress tolerance was a mediator in both models
| b | SE | t | β | p | CI | |
|---|---|---|---|---|---|---|
| Gut-specific anxiety outcome modela | ||||||
| Constant | 53.94 | 5.74 | 9.40 | - | < .001 | 42.67–65.20 |
| Anxiety sensitivity | 0.31 | 0.05 | 6.67 | 0.23 | < .001 | 0.22–0.40 |
| Distress tolerance | − 5.88 | 0.73 | − 8.01 | − 0.28 | < .001 | − 7.32 – −4.44 |
| Gender (male) | 1.31 | 1.37 | 0.96 | 0.03 | 0.34 | − 1.37–3.99 |
| Age (years) | − 0.11 | 0.05 | − 1.96 | − 0.06 | 0.05 | − 0.21–0.00 |
| Income | 0.06 | 0.35 | 0.17 | 0.01 | 0.86 | − 0.63–0.66 |
| Education | 0.14 | 0.27 | 0.52 | 0.02 | 0.60 | − 0.38–0.66 |
| Total effect | 0.45 | 0.05 | 10.11 | - | < .001 | 0.37–0.54 |
| Direct effect | 0.31 | 0.05 | 6.67 | - | < .001 | 0.22–0.40 |
| Completely standardized indirect effect via distress tolerance | - | - | - | 0.11 | - | 0.07–0.14b |
| Anxiety sensitivity outcome modelc | ||||||
| Constant | 43.90 | 4.12 | 10.64 | - | < .001 | 35.80–51.99 |
| Gut-specific anxiety | 0.17 | 0.03 | 6.67 | 0.22 | < .001 | 0.12–0.21 |
| Distress tolerance | − 4.67 | 0.53 | − 8.81 | − 0.29 | < .001 | − 5.71 – −3.63 |
| Gender (male) | 1.53 | 0.99 | 1.54 | 0.05 | 0.12 | − 0.42–3.48 |
| Age (years) | − 0.19 | 0.04 | − 4.88 | − 0.15 | < .001 | − 0.27 – −0.11 |
| Income | − 0.48 | 0.26 | − 1.86 | − 0.06 | 0.06 | − 0.98–0.03 |
| Education | − 0.23 | 0.19 | − 1.17 | − 0.04 | 0.24 | − 0.61–0.15 |
| Total effect | 0.24 | 0.02 | 10.11 | - | < .001 | 0.20–0.29 |
| Direct effect | 0.17 | 0.02 | 6.67 | - | < .001 | 0.12–0.21 |
| Completely standardized indirect effect via distress tolerance | - | - | - | 0.11 | - | 0.07–0.14b |
n = 826, R2 = 0.20
BootLLCI-BootULCI
n = 826, R2 = 0.25
To examine the hypotheses from a more detailed perspective, additional models (n = 14) were tested except using the four subscales of the Distress Tolerance Scale (i.e., Tolerance, Absorption, Appraisal, and Regulation) as mediators, or the three subscales of the Anxiety Sensitivity Scale (i.e., Physical, Cognitive, or Social Concerns) as the predicting/outcome variable. SPSS outputs with all the model results are provided as an online supplement. Of note, though the overall conclusion did not change, the model that accounted for the largest amount of variance was when the Distress Tolerance Appraisal subscale was used as a mediator between gut-specific anxiety as a predictor and overall anxiety sensitivity as an outcome (R2 = 0.27).2
Discussion
The purpose of this study was to assess the mediating and moderating roles of distress tolerance in the relation between anxiety, more broadly, and gut-specific anxiety, utilizing cross-sectional data. Consistent with the first hypothesis, anxiety sensitivity was significantly associated with gut-specific anxiety. A unique finding, and consistent with the second hypothesis, distress tolerance was a significant mediator of the relation between anxiety and gut-specific anxiety. Though the moderation models were not statistically significant, given the cross-sectional nature of this dataset, multiple models supported the final hypothesis of distress tolerance being related to both anxiety and gut-specific anxiety. This is the first known study to demonstrate these broad associations between distress tolerance, anxiety sensitivity, and gut-specific anxiety.
Given the cross-sectional nature of the study, and while none of the models tested seem to have statistical utility over one another, theory should be utilized to guide interpretation of the current study’s findings. Of all the models tested, models with anxiety sensitivity as the dependent variable accounted for the largest amount of variance. This finding is generally supported by theory regarding the generalization of learned behavior [34]. It could be that individuals experiencing significant gastrointestinal distress or gut-specific anxiety develop less tolerance for distress and thereby develop more sensitivity to more general anxiety symptoms. Alternatively, it is possible that a slightly elevated level of gut-specific anxiety could be adaptive, in nature (e.g., someone diagnosed with a chronic GI disorder having a lower tolerance for distress and is thereby more readily aware of available toilets in new places in case of an emergency). Given that regression models impose hypothesized relation but do not inherently imply directionality, these findings may provide a useful starting point in a more experimental or causal research design. Here, the data simply provide preliminary associations that could be built upon with more appropriate designs that can accurately demonstrate the directionality in this relation.
Considering the stress-diathesis model [35], the non-significant moderation findings here suggest no particular synergistic interaction exists between gut-specific distress and anxiety more broadly with distress tolerance. Rather, given the mediation results, the relationship between these variables seems to be more additive in nature (e.g., poorer distress tolerance could lead to both greater anxiety and greater gut-specific anxiety). These conceptual views are speculative, and additional longitudinal work is required to track the development of distress tolerance (or intolerance) as a result of anxiety or fearful experiences.
Conceptually, this work suggests that an increase in gut-specific anxiety precipitates lower tolerance for distress, which could be associated with the propensity to experience higher levels of trait-like anxiety sensitivity, or vice versa [36]. That is, the development and maintenance of gut-specific anxiety and or anxiety sensitivity could be due, in part, to an underlying inability to tolerate emotionally demanding situations, uncomfortable situations (i.e., distress), or physiological discomfort (i.e., abdominal pain, nausea). Over time, behaviors, cognitions, sensations, and emotions related to poorer distress tolerance likely are learned as a result of gut-specific anxiety and/or overall anxiety sensitivity and could eventually perpetuate anxiety-like symptoms [36].
Though this study was not specific to a clinical sample, one may speculate that low distress tolerance may be a risk factor for developing anxiety and/or gut-related pathologies. More work in this area with a GI-specific clinical population would be advantageous. Distress tolerance could influence anxiety disorder ontology, or certain anxiety disorders might decrease distress tolerance as a symptom. Understanding the specific mechanisms of distress tolerance could impact the understanding of various anxiety disorders and anxiety-related symptomatology. Similarly, additional investigation into distress tolerance may play an important role in anxiety disorder and gastrointestinal disorder maintenance and treatment.
Individuals with digestive diseases may have a lower tolerance for gut sensations as they may associate them with negative consequences, such as the beginning of a disease flare-up, or the experience of diarrhea or constipation. Distress tolerance should be considered as a possible treatment target for patients with anxiety and GI disorders. Though cognitive-behavioral therapies for anxiety disorders undoubtedly target emotional or psychological distress tolerance, they often do so indirectly through focusing on patient thoughts and behaviors. Perhaps directly targeting distress tolerance in CBT sessions for anxiety and gut-related disorders would increase therapy effectiveness and efficiency, much like the manner of addressing distress tolerance in dialectical behavior therapy [37] or acceptance and commitment therapy [38] for other disorders (e.g., borderline personality disorder or anxiety disorders). Also, for behavioral therapies, distress tolerance could logically play a major role in influencing patient willingness to expose themselves to negative situations. Similarly, low distress tolerance may influence a patient’s ability to gradually expose themselves to subjectively aversive circumstances. Thus, specifically targeting distress tolerance in a therapeutic session might increase the outcomes of those with anxiety and gut distress.
Several limitations may have impacted the conclusions of this study. One such limitation already mentioned was the cross-sectional design of this study. No causal or directional conclusions can be claimed or implied from these findings. Additional prospective or experimental work should be designed to explore the various models tested to validate and test causal hypotheses as to the relation and directionality in terms of the role of distress tolerance in anxiety and gut-specific anxiety. Mediation models are useful, however, to test and interpret some predictive hypotheses such as some of the models tested here.
Another limitation was that study participants were not selected based on any gut-related or anxiety-related issues. The generality of the sample may limit the results of the study to relevant clinical populations. Future studies may explore distress tolerance as a mediator of the relation between anxiety sensitivity and gut-specific anxiety in those with gastrointestinal or anxiety disorders, such as irritable bowel syndrome, inflammatory bowel disease, or generalized anxiety disorder. Understanding distress tolerance as a factor that may influence general and gut-specific anxiety in a population that is suffering from such anxieties is critical for clinical relevance. Such future research could build upon the current study’s result suggesting that distress tolerance mediates the relation between anxiety sensitivity and gut-specific anxiety in a more general population. Similarly, the shared method (i.e., self-report) and nature of this study is a limitation, and may have influenced the results through reporting style or bias.
Finally, the vast majority of participants sampled reported being White. This limitation could impact the generalizability of the results to other racial and ethnic groups. Other study limitations include the slight oversampling of females, the well-educated, and the middle-class, as well as all imprecision associated with the study measures (measurement error).
Conclusion
As the first known study to examine the role of distress tolerance as a mechanism to explain the relation between anxiety and gut-specific anxiety, the present results necessitate further examination of the causal and directional relations between these variables. A clearer picture is needed to understand distress tolerance as a mediator underlying gut-related disorders and their etiological factors. An extended conceptualization of the components of distress tolerance likely could lead to more informed psychotherapeutic techniques that could help to alleviate the psychosomatic symptoms associated with anxiety and gut-related disorders.
Supplementary Material
Acknowledgments
The authors would like to thank all the participants for their contributions to this work.
Funding Information
This study was funded by the National Institute of Dental and Craniofacial Research (NIDCR F31-DE027859, R01-DE014889 and R21-DE026540) and by the National Institute of General Medical Sciences (NIGMS T32-GM132494).
Footnotes
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12529-020-09912-6) contains supplementary material, which is available to authorized users.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent Informed consent was obtained from all individual participants included in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
Fear and stress also are likely involved; the terminology in describing these states is inexact, so “anxiety” will be used as an omnibus term for the purposes of this paper (see Felicione et al. [7]).
Moderation models also were conducted. Distress tolerance was not a statistically significant moderator in the relation between anxiety sensitivity and gut-specific anxiety while accounting for covariates.
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