Distress intolerance and clinical functioning in persons with schizophrenia
Introduction
Understanding the contributing factors to functional impairment in persons with schizophrenia (SZ) remains a critical research area. SZ is marked by heightened sensitivity to stress (Norman and Malla, 1993, Corcoran et al., 2003, Walker et al., 2008). This sensitivity, combined with reduced cognitive reserve (Barnett et al., 2006), may predispose those with the illness to have difficulty successfully navigating stress-inducing situations and completing tasks that invoke stress. It is known that as a group, SZ patients have reduced drive to pursue goal directed behavior and display altered physiological responses to induced stress (Albus et al., 1982, Breier et al., 1988, Jansen et al., 1998, Jansen et al., 2000). For example, SZ exposed to a mental arithmetic stress test displayed an abnormal prolonged cardiac autonomic response which is hypothesized to arise from alterations in central brain structures which leave patients unable to “switch off” the stress response (Castro et al., 2008). This autonomic dysfunction was also found in unaffected first-degree relatives, suggesting that this abnormality has a genetic etiology rather than being due to arousal secondary to the disease or psychiatric medication effects (Bar et al., 2010). It is unknown if a maladaptive stress response contributes to their inability to complete tasks that evoke stress. We utilized a distress intolerance (defined as an inability to persist in goal directed behavior while experiencing affective distress) paradigm to test this question (Leyro et al., 2010). Distress tolerance is a meta-emotion construct encompassing an individual׳s evaluations of experiencing aversive emotional states in respect to their tolerability, influence on emotion regulation and functioning, specifically including tendencies to either avoid or attenuate aversive experiences (Simons and Gaher, 2005). The definition of distress intolerance we employed bears resemblance to persistence, a trait-like dimension. Although the definition of persistence is not uniform, it is related to maintaining certain behavior for achieving reinforcement or a reward (Cloninger et al., 1991). Other authors have described completion of experimental tasks, some of which were designed to evoke frustration or distress, wherein the participants had the option to give up attempts at completing the task, as task persistence (Brandon et al., 2003). In the latter case, the construct is closely related to distress tolerance. The construct of task persistence is built upon Eisenberger׳s learned industriousness theory, which holds that organisms with prior experience being rewarded for high effort are more likely to persist at effortful tasks than are organisms with histories of being rewarded for low effort (Eisenberger et al., 1992). Thus, distress intolerance and task persistence are similar in that both are operationalized by experimental tasks measuring the duration of a person׳s attempt; however they differ in their theory upon which the construct is based.
Distress intolerance has been found relevant to other psychiatric and pathological conditions, and adaptive response to stress is increasingly a target of psychological interventions (Daughters et al., 2005a, Daughters et al., 2005b, O’Cleirigh et al., 2007, Nock and Mendes, 2008). For example, high levels of affect reactivity and distress intolerance have been associated with poor outcome after substance abuse and pathological gambling treatment (Daughters et al., 2005a, Daughters et al., 2005b). Patients with distress intolerance experienced greater depression, substance use, and were less adherent to their medication (O’Cleirigh et al., 2007). Distress intolerance has also been found in adolescents engaging in nonsuicidal self-injury (Nock and Mendes, 2008). To our knowledge, distress intolerance has not been examined in persons with SZ in a laboratory setting.
We operationalized distress intolerance by measuring a behavioral response to laboratory tasks that induced psychological stress. We utilized paradigms in which participants had the option to terminate the distress challenge task early. To motivate participants not to terminate early, they were informed that their performance determined their monetary reward. Early termination of the stressful task could result from: increases in negative affect, decreased motivation to persist due to an inability to experience anticipatory pleasure, or from an impulsive decision; thus we assessed these attributes in relation to distress intolerance. SZ patients in particular have less anticipatory pleasure for goal directed activities (Gard et al., 2007); thus we felt it was important to control for the constructs of anhedonia and avolition while exploring this stress paradigm. While cognitive functioning has previously been shown to represent a separate domain from stress induced emotional reactivity in SZ (Myin-Germeys et al., 2002), due to its association with functional outcome we investigated its relationship with distress intolerance. We investigated: 1) whether SZ had more or less intolerance to psychological distress as compared with healthy controls; 2) the extent to which negative and positive affect reactivity, clinical and cognitive impairments explained distress intolerance and functional capacity, and 3) the extent by which functional impairments in SZ are explained by distress intolerance.
Section snippets
Participants
Participants were 130 individuals, aged 18 to 62 years, including 43 healthy controls and 65 outpatients with SZ or schizoaffective disorder. Participants gave written informed consent as approved by the University of Maryland Institutional Review Board. Major medical and neurological illnesses, history of head injury with cognitive sequelae, mental retardation, substance dependence within the past six months, or current substance abuse (except nicotine) were exclusionary. The Structured
Clinical characteristics
Patients and controls were frequency-matched in age (P=0.489) and sex (P=0.085), however, patients had lower education (P=0.004) and a greater percentage of smokers (P=0.014) compared with controls (Table 1). SZ had significantly more psychiatric symptoms, greater impulsiveness, worse functional capacity, and worse cognitive performance (all P<0.001).
Distress intolerance in SZ
SZ patients showed increased distress intolerance such that they were significantly more likely to terminate the tasks early as compared to
Discussion
In this study, we found relatively clear evidence of increased distress intolerance in SZ, which was significantly associated with their impaired functional capacity and cognition. Interestingly, distress intolerance was not associated with severity of psychiatric symptoms in SZ. Distress intolerance had an independent effect on functional capacity, and also an indirect effect on functional capacity through cognition.
Symptom severity and cognitive impairments are known to be related to
Author disclosure
A portion of this work was presented at the International Congress on Schizophrenia Research on April 25, 2013.
Contributors
EH and SD designed the study. KN analyzed the data and wrote the first draft of the manuscript, and all authors (KN, JC, LR, SD, and EH) wrote and read the subsequent drafts and approved the final submitted manuscript.
Acknowledgment
We would like to thank our study participants and the staff of the Neuroimaging Research Program at the Maryland Psychiatric Research Center. This work was supported by National Institutes of Health grants T32MH067533, R01MH085646, R01DA027680, and R21DA033817.
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