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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: J Clin Psychol. 2020 Feb 18;76(9):1668–1676. doi: 10.1002/jclp.22944

Levels of distress tolerance in schizophrenia appear equivalent to those found in borderline personality disorder

Kelsey A Bonfils 1,2, Paul H Lysaker 3,4
PMCID: PMC7725405  NIHMSID: NIHMS1574837  PMID: 32068895

Abstract

Objective:

Distress tolerance is an important but understudied construct for those with schizophrenia-spectrum disorders. This study compared levels of distress tolerance between people diagnosed with schizophrenia and borderline personality disorder in order to better characterize distress tolerance in schizophrenia-spectrum disorders.

Method:

Using cross-sectional data, we examined group differences in distress tolerance in people with schizophrenia-spectrum disorders (N=55) and borderline personality disorder (N=32) through mean comparison and equivalence analyses.

Results:

Our results indicate that, in our data, distress tolerance did not differ between those with schizophrenia and those with borderline personality disorder, and was in fact statistically equivalent between groups. In contrast, those with borderline personality disorder tended to report more difficulty on some aspects of emotion regulation.

Conclusion:

Findings from this study suggest that increased focus on distress tolerance is called for in research on schizophrenia. Furthermore, people with schizophrenia-spectrum disorders may benefit from interventions targeting distress tolerance.

Keywords: distress tolerance, emotion regulation, schizophrenia, borderline personality disorder, psychotic symptoms

Distress tolerance refers to the capacity to experience and tolerate aversive psychological states (Simons & Gaher, 2005). People who have low distress tolerance may experience distress as unbearable and/or have the belief that they are unable to cope with being upset or distressed. Research suggests that people with schizophrenia have reduced distress tolerance as compared to healthy control samples (Chiappelli et al., 2014; Nugent, Chiappelli, Rowland, Daughters, & Hong, 2014). Indeed, early work has linked lower distress tolerance to reduced social functioning (Nugent et al., 2014), negative mood states (Stanage-Becker, 2009), cognitive deficits (Nugent et al., 2014), and psychotic symptoms (Bonfils, Minor, Leonhardt, & Lysaker, 2018; Stanage-Becker, 2009).

While distress tolerance has been linked to important clinical symptoms and outcomes in schizophrenia, the construct has received remarkably little attention in the field of psychosis research. This is likely because distress tolerance is not acknowledged in the diagnostic criteria for schizophrenia or schizoaffective disorder (American Psychiatric Association, 2013), nor is it common to address distress tolerance in treatment protocols designed for people with psychotic illnesses. This stands in contrast to the broader literature on psychopathology. Indeed, interventions for various disorders have been developed that directly or indirectly target ability to tolerate distress, such as Dialectical Behavioral Therapy (DBT; Linehan, 1993a), Acceptance and Commitment Therapy (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), and Mindfulness Based Cognitive Therapy (Teasdale et al., 2000).

There are multiple reasons to study distress tolerance in schizophrenia. Despite the common negative symptom of blunted affect, people with schizophrenia-spectrum disorders report experiencing similar internal emotional experiences to healthy control samples (Kring & Moran, 2008). Recent research has also shown a robust effect wherein people with schizophrenia-spectrum disorders report experiencing greater personal distress (i.e., internal, self-oriented distress upon seeing the negative situations of others) than healthy control samples (Bonfils, Lysaker, Minor, & Salyers, 2017). Further, a meta-analysis has shown that people with schizophrenia-spectrum disorders report heightened arousal in response to neutral stimuli, suggesting that people with these disorders may be in a higher state of arousal, even at rest (Llerena, Strauss, & Cohen, 2012). Similarly, a meta-analysis of emotional experience found that people with schizophrenia-spectrum disorders report greater experience of negative emotions in response to neutral or even positive stimuli (Cohen & Minor, 2010). Together, results suggest that people with schizophrenia-spectrum disorders experience notable internal distress and that this distress may be prevalent even in relatively non-aversive settings. This is in line with theoretical suggestions that people with schizophrenia-spectrum disorders experience heightened negative emotion, but have reduced ability to tolerate and downregulate negative affect, leading to potential functional consequences (Bonfils et al., 2017; Cohen & Minor, 2010; Horan, Green, Kring, & Nuechterlein, 2006; Horan et al., 2015; Strauss et al., 2013). Though not yet investigated in schizophrenia-spectrum samples, low distress tolerance has also been linked to suicidal ideation (Anestis, Bagge, Tull, & Joiner, 2011; Vujanovic, Berenz, & Bakhshaie, 2017) and substance abuse (Bujarski, Norberg, & Copeland, 2012), important clinical issues with large effects on safety and quality of life. Thus, further work is needed to increase understanding of the ability to tolerate distress in this population.

One basic question that remains unclear is whether people with schizophrenia-spectrum disorders report similar levels of distress tolerance to other psychiatric groups. Distress tolerance has been studied in relation to anxiety symptoms (Pawluk & Koerner, 2016), substance use disorders (Ali, Green, Daughters, & Lejuez, 2017), mood symptoms (Ameral, Bishop, & Palm Reed, 2017), and personality disorders (Cavicchioli, Rugi, & Maffei, 2015). The disorder with perhaps the most research on distress tolerance is borderline personality disorder (BPD). Indeed, Linehan’s (Linehan, 1993a) early theoretical work on BPD suggests that inability to tolerate distress (coupled with emotional dysregulation) is a key factor in the disorder’s symptomatic presentation, and is especially linked to self-injurious behavior and suicide attempt. Linehan’s early work launched an extensive body of literature examining distress tolerance in BPD, and the gold-standard treatment for the disorder, DBT, explicitly addresses distress tolerance skills.

A second, more nuanced question concerns emotion regulation in BPD and schizophrenia – the processes involved in monitoring, evaluating, and altering emotions in order to achieve goals (Thompson, 1994). Emotion regulatory capacities have also been investigated in schizophrenia-spectrum disorders, at considerably more depth than distress tolerance. Studies suggest that people with schizophrenia-spectrum disorders may be less effective when attempting to use emotion regulatory strategies than healthy control participants (Painter, Stellar, Moran, & Kring, 2019; Strauss et al., 2013, 2015; Visser, Esfahlani, Sayama, & Strauss, 2018). This is similar to research on BPD suggesting that the emotional dysregulation seen in the disorder emanates from both inadequate use of appropriate regulatory strategies as well as overuse of maladaptive regulatory strategies (Carpenter & Trull, 2013). Emotion regulation and distress tolerance are related constructs. Indeed, ability to tolerate distress has direct influence on emotion regulatory needs and strategies, with those who have low tolerance more likely to expend great effort to avoid experiencing negative emotions (Simons & Gaher, 2005). As such, research on distress tolerance is a complement to existing research on emotion regulation in schizophrenia-spectrum disorders, and examining group differences in both constructs will shed light on how people with schizophrenia-spectrum disorders experience and respond to aversive emotional phenomena.

To address these two questions, we assessed distress tolerance in participants with schizophrenia or schizoaffective disorder and compared to participants diagnosed with borderline personality disorder. Our main goal was to compare self-reported distress tolerance between these two groups in order to characterize schizophrenia-spectrum disorders as compared to a group with well-researched deficits in distress tolerance. A secondary goal was to compare the two groups on emotion regulation. We hypothesized, in light of literature suggesting increased experience of distress in people with schizophrenia-spectrum disorders as well as inadequate emotion regulatory capacities, that those with schizophrenia or schizoaffective disorder would not differ from those with borderline personality disorder in their self-reported ability to tolerate distress. We hypothesized similarly for analyses on emotion regulation.

Method

Participants

Participants with schizophrenia-spectrum disorders (N=55) were recruited from an outpatient psychiatry clinic of a VA Medical Center or from an urban community mental health center and provided data as part of a larger randomized controlled trial. Only data from baseline assessments were used in this investigation. Participants with borderline personality disorder (N=32) were recruited as part of two separate studies investigating metacognitive correlates, both at a VA Medical Center. Across samples, all participants were receiving ongoing outpatient psychiatric care and had not been hospitalized or had medication changes in the past month. Patients were excluded if they had active substance dependence.

Measures

Ability to tolerate distress was assessed with the Distress Tolerance Scale (DTS; (Simons & Gaher, 2005), a 15-item self-report scale using a Likert-style response format. The original validation study for this measure used anchor points where 1 corresponded to “strongly agree” and 5 corresponded to “strongly disagree;” these were reversed in the present study so that 1 corresponded to “strongly disagree” and 5 corresponded to “strongly agree.” Total scores on the DTS are calculated by averaging item scores together, and higher scores in these samples suggest reduced ability to withstand emotional distress (i.e., distress intolerance). Past work indicates acceptable internal consistency, test-retest reliability, and construct validity (Simons & Gaher, 2005); internal consistency was also acceptable in this study (alpha = .88).

Emotion regulation was assessed with the Difficulties in Emotion Regulation Scale (DERS; (Gratz & Roemer, 2004), a 36-item self-report scale using a Likert-style response format where 1 corresponds to “almost never” and 5 corresponds to “almost always.” The DERS produces a total score as well as six subscale scores: lack of emotional clarity, limited access to emotion regulation strategies, lack of emotional awareness, impulse control difficulties, difficulties engaging in goal-directed behavior, and nonacceptance of emotional responses. Scores on the DERS were calculated as the average item response, and higher scores indicate more difficulty with regulating emotions. Past work indicates acceptable internal consistency, test-retest consistency, and construct validity in development (Gratz & Roemer, 2004) as well as psychotic samples (Owens, Haddock, & Berry, 2013) and samples of persons with BPD (Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006). Evidence from this study suggests adequate internal consistency for the total (alpha = .93) as well as subscale scores (alpha range .68–.86).

Procedure

Diagnoses for the schizophrenia-spectrum and borderline personality samples were confirmed with the SCID for DSM-IV-TR (First, Spitzer, Gibbon, & Williams, 2001) or the SCID for DSM-IV Axis II Personality Disorders, respectively (First, Gibbon, Spitzer, Williams, & Benjamin, 1997). Interviews were conducted by trained research associates across studies. All procedures were approved by the relevant institutional review boards.

Analyses

Descriptive statistics were first conducted to define the demographic characteristics of the groups. A series of Welch’s independent samples t-tests were conducted to examine group differences for both distress tolerance and emotion regulation scores, including DERS subscales. Welch’s was chosen rather than Student’s due to unequal group sizes (Delacre, Lakens, & Leys, 2017). Then, we conducted equivalence testing using the two one-sided tests (TOST) procedure (Lakens, 2017). The TOST procedure assesses whether the effect size of the difference between groups falls within pre-determined equivalence bounds. We chose to consider our groups equivalent if the absolute value of the effect size was less than 0.5 (Cohen’s d). Use of effect sizes allowed for consistent standards across subscale comparisons. The TOST procedure statistically tests whether the effect size is significantly different from each equivalence bound, producing two sets of one-sided t-test statistics. If both t-tests are found to be significant, results can be interpreted to suggest equivalence of scores between groups. When conducted in tandem with traditional independent samples t-tests, analyses can inform both whether group scores are different and whether group scores are equivalent (Lakens, 2017).

Results

The majority of participants in both groups were male (schizophrenia-spectrum: n=37, 67%; borderline personality: n=26, 81%). The average age of the schizophrenia-spectrum sample was 51 years (SD=10.8), while the average in the borderline personality sample was 49 years (SD=12.5). Neither gender nor age significantly differed between groups.

Descriptive statistics for the DTS and DERS can be found in Table 1. Regarding distress tolerance, results revealed that scores on the DTS did not differ between groups. Regarding emotion regulation, results also revealed that DERS total scores did not differ between groups. Results were similar for DERS scores on the following subscales: nonacceptance of emotion response, difficulties engaging in goal-directed behavior, impulse control difficulties, limited access to emotion regulation strategies, and lack of emotional clarity. For lack of emotional awareness, groups differed such that participants in the borderline personality group reported more problems with awareness of their emotions than did the schizophrenia-spectrum group. The two groups only significantly differed by conventional standards on one DERS subscale; however, it should be noted that group differences at the level of p=.06–.07 emerged for the DERS total score and difficulties engaging in goal-directed behavior, both such that those with borderline personality disorder reported greater difficulty than those with schizophrenia-spectrum disorders.

Table 1 –

Descriptive statistics by group for distress tolerance and emotion regulation measures

Schizophrenia-Spectrum Mean (SD) BPD Mean (SD) Independent Samples t-test statistic TOST t-test statistic
Distress Tolerance Scale 3.24 (0.78) 3.21 (0.94) t(55.77)=−0.15, p=.88 t(55.68)=−2.04, p=.02
DERS-Total 2.61 (0.71) 2.90 (0.65) t(69.45)=1.91, p=.06 t(69.70)=0.34, p=.37
DERS-Nonacceptance of Emotional Responses 2.69 (1.02) 2.52 (1.15) t(59.07)=−0.84, p=.40 t(58.80)=−1.52, p=.07
DERS-Lack of Emotional Clarity 2.44 (0.81) 2.76 (0.97) t(55.29)=1.58, p=.12 t(55.97)=0.62, p=.27
DERS-Limited Access to Emotion Regulation Strategies 2.62 (0.90) 2.96 (1.05) t(56.77)=1.45, p=.15 t(57.17)=0.67, p=.25
DERS-Lack of Emotional Awareness 2.45 (0.85) 2.94 (0.89) t(62.42)=2.62, p=.01 t(62.52)=−0.28, p=.61
DERS-Impulse Control Difficulties 2.38 (1.04) 2.73 (0.84) t(76.19)=1.67, p=.10 t(76.17)=0.60, p=.28
DERS-Difficulties Engaging in Goal-Directed Behavior 3.12 (0.98) 3.55 (1.12) t(57.45)=1.86, p=.07 t(58.15)=0.40, p=.34
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Note: BPD = borderline personality disorder. DERS = Difficulties in Emotion Regulation Scale. SD = standard deviation. TOST = two one-sided tests. For all measures and subscales, higher scores indicate greater difficulty, with a range of 1–5. For TOST results, the t-statistic with the larger p-value is reported, per Lakens (2017).

In equivalence analyses, results revealed that the scores on the DTS can be considered statistically equivalent across groups. Thus, for the DTS, we can interpret results to suggest that group scores do not differ, and they are equivalent. For the DERS, equivalence analyses did not reach significance for the total score or for any subscale, though the subscale nonacceptance of emotional responses was nearing significance for equivalence of group scores (p=.07).

Discussion

This study aimed to investigate two questions – do people with schizophrenia-spectrum disorders report similar or different levels of distress tolerance compared to people with BPD, a disorder for which deficits in distress tolerance have been more comprehensively described, and do groups look similar for levels of emotion regulation? As predicted, results suggest that adults in these two groups did not differ from one another in their reports of ability to tolerate distress, and indeed can be considered statistically equivalent. Results of analyses examining emotion regulation revealed that some aspects of emotion regulation did not differ between groups, including nonacceptance of emotional responses, impulse control difficulties, limited access to emotion regulation strategies, and lack of emotional clarity. However, against hypotheses, the subscale lack of emotional awareness did significantly differ between groups, such that those with borderline personality disorder reported greater difficulty in this domain, and there was a statistical trend suggesting differences between groups for the overall score and for difficulties engaging in goal-directed behavior. Furthermore, no emotion regulation score reached statistical significance when considering equivalence across groups.

In our data, people with schizophrenia-spectrum disorders experienced significant difficulty tolerating distress, similar to that experienced by those with BPD, a diagnostic group characterized by a reduced ability to tolerate distress (Linehan, 1993a). Distress tolerance has been minimally researched in this population, but results of this study suggest that continued research on this construct may be fruitful in further exploring the emotional experience and difficulties of those with schizophrenia-spectrum disorders. It is possible that reduced ability to tolerate distress in this group, which has been shown to endorse higher levels of negative emotion (Bonfils et al., 2017; Cohen & Minor, 2010), may negatively affect functional capabilities (Bonfils et al., 2018). Further work is needed to grow our knowledge on distress tolerance in schizophrenia-spectrum disorders and investigate potential impacts on functional outcomes in larger samples.

Results regarding the related construct of emotion regulation paint a more complex picture. Taken at face value, results may suggest that people with schizophrenia-spectrum disorders report having difficulties in emotion regulation that do not significantly differ from those reported by people with BPD, with the exception of the lack of emotional awareness subscale, where people with BPD reported significantly more problems with awareness and understanding of emotions than those with schizophrenia-spectrum disorders. However, the alpha values for emotion regulation analyses suggest that with a larger sample, the two groups may also show significant differences in the ability to control behavior in the service of goal-attainment when experiencing negative emotion (i.e., the difficulties engaging in goal-directed behavior subscale) as well as overall emotion regulation (i.e., the DERS total score) -- both findings suggesting that people with BPD report having more difficulty in regulating emotions than those with schizophrenia-spectrum disorders. These results are notable in light of the smaller samples available in this study and may reach significance in replications with larger samples. Consistent with the above findings, no emotion regulation score displayed statistical evidence of equivalence across groups (though there was a trend in the tendency to not accept or value one’s own emotional responses, suggesting similarities across groups for this one aspect of emotion regulation).

Overall, results suggest a pattern of poorer emotion regulation in BPD than in schizophrenia-spectrum disorders, contrary to hypotheses. This may suggest a key difference between these groups in how they are able to understand and respond to their emotions, as opposed to the experience of negative emotions as aversive and intolerable, which is equivalent across groups. Alternatively, there is work suggesting that people with schizophrenia tend to overestimate their social emotional abilities as compared to reports from outside observers and performance-based measures (Bonfils, Lysaker, Minor, & Salyers, 2016; Bora, Gökçen, & Veznedaroglu, 2008; Lysaker, Hasson-Ohayon, Kravetz, Kent, & Roe, 2013). It is possible this same self-report bias comes into play in reporting on one’s own emotions and the ability to regulate them, which may contribute to the trending differences between groups seen in this study. Future work is needed to replicate findings and parse apart these possibilities.

This study has limitations. The study was cross-sectional, and group sample sizes were small. Both groups were also composed largely of male Veterans, which limits generalizability of results. This is particularly true for the BPD group, as estimates of BPD diagnoses in the general population suggest about 75% are women (American Psychiatric Association, 2013). As such, our results can be interpreted as most applicable for Veterans with psychopathology. Future studies should replicate results with larger, more diverse patient samples that more closely reflect population demographics. In addition, self-report measures of distress tolerance and emotion regulation were used here, and results may differ with performance- or task-based assessments. Lastly, this work is limited in that we cannot comment on mechanistic factors leading to deficits in distress tolerance in either group. While transdiagnostic comparisons such as the one presented here are valuable and in line with trends in the field toward psychopathology on a continuum, we are unable to determine differences or similarities in the pathogenesis of a given deficit seen across multiple disorders. It is possible that distress tolerance deficits in schizophrenia-spectrum disorders and BPD are linked to factors specific to those conditions, as opposed to a broader deficit seen across psychopathology.

With replication, results may have clinical implications. Our findings suggest that interventions for difficulties with distress tolerance, which are a key component of gold-standard treatment for BPD (Linehan, 1993b), may also be of value for those diagnosed with schizophrenia-spectrum disorders. Traditional approaches to treatment of schizophrenia-spectrum disorders focus on medication and, often, skills-based or resource interventions to mitigate functional deficits and improve outcomes (i.e., psychiatric rehabilitation; Corrigan, Mueser, Bond, Drake, & Solomon, 2009). Psychotherapy has also received increasing attention in recent years and has potential to positively influence distress tolerance for this population (Hogarty et al., 1995; Lysaker & Klion, 2017; Lysaker et al., 2015). Future research should continue to investigate improvement in distress tolerance over the course of available psychotherapies and explore ways that techniques currently used with success in BPD treatment may be refined for use in schizophrenia-spectrum disorders.

Acknowledgments

Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number 4R01MH094310-04. Additional partial support for K. Bonfils was provided by the VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC; Director: D. Oslin; Associate Director: G. Haas), VA Pittsburgh Healthcare System. The contents of this manuscript do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

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