Cognitive Therapy and Research

, Volume 37, Issue 3, pp 456–465 | Cite as

Rumination Mediates the Relationship Between Distress Tolerance and Depressive Symptoms Among Substance Users

  • Jessica F. Magidson
  • Alyson R. Listhaus
  • C. J. Seitz-Brown
  • Katelyn E. Anderson
  • Briana Lindberg
  • Alexis Wilson
  • Stacey B. Daughters
Original Article


Distress tolerance has been implicated in the emergence of internalizing symptomatology, notably depressive symptoms. However, few studies have tested potential mechanisms underlying the relationship between distress tolerance and depressive symptoms, and further, this has not been tested among substance users, who commonly experience both low distress tolerance and elevated depressive symptoms. The current study focused on the construct of rumination, which has been suggested to be a coping response to stress associated with substance use and depression. Two forms of rumination, brooding and reflection, were tested as potential mediators of the relationship between distress tolerance and self-reported depressive symptoms among 128 individuals entering substance abuse treatment. Brooding (i.e., to overly focus on symptoms of distress) mediated the relationship between distress tolerance and depressive symptoms. However, reflection (i.e., to attempt to gain insight into problems) was unrelated to distress tolerance. Findings suggest the important role of brooding as a mechanism underlying the relationship between distress tolerance and depressive symptomatology.


Distress tolerance Depressive symptoms Rumination Brooding Reflection Substance use 



This work was supported by National Institute of Drug Abuse Grants R01 DA026424 and R01 DA022974 (PI: Daughters).


  1. Abela, J. Z., & Hankin, B. L. (2011). Rumination as a vulnerability factor to depression during the transition from early to middle adolescence: A multiwave longitudinal study. Journal of Abnormal Psychology, 120(2), 259–271. doi: 10.1037/a0022796.PubMedCrossRefGoogle Scholar
  2. Abrantes, A. M., Strong, D. R., Lejuez, C. W., Kahler, C. W., Carpenter, L. L., Price, L. H, et al. (2008). The role of negative affect in risk for early lapse among low distress tolerance smokers. Addictive Behaviors, 33, 1394–1401.PubMedCrossRefGoogle Scholar
  3. Bagby, R., & Parker, J. A. (2001). Relation of rumination and distraction with neuroticism and extraversion in a sample of patients with major depression. Cognitive Therapy and Research, 25(1), 91–102. doi: 10.1023/A:1026430900363.CrossRefGoogle Scholar
  4. Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R., & Fiore, M. C. (2004). Addiction motivation reformulated: An affective processing model of negative reinforcement. Psychological Review, 111(1), 33–51. doi: 10.1037/0033-295X.111.1.33.PubMedCrossRefGoogle Scholar
  5. Baron, R., & Kenny, D. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182.PubMedCrossRefGoogle Scholar
  6. Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment, 67(3), 588.PubMedCrossRefGoogle Scholar
  7. Bjornsson, A., Carey, G., Hauser, M., Karris, A., Kaufmann, V., Sheets, E., et al. (2010). The effects of experiential avoidance and rumination on depression among college students. International Journal of Cognitive Therapy, 3(4), 389–401. doi: 10.1521/ijct.2010.3.4.389.CrossRefGoogle Scholar
  8. Borkovec, T. D. (1994). The nature, functions, and origins of worry. In G. L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory, assessment and treatment (pp. 5–33). Oxford England: Wiley.Google Scholar
  9. Borkovec, T. D., Ray, W. J., & Stöber, J. (1998). Worry: A cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes. Cognitive Therapy and Research, 22(6), 561–576. doi: 10.1023/A:1018790003416.CrossRefGoogle Scholar
  10. Brown, R. A., Lejuez, C. W., Kahler, C. W., Strong, D. R., & Zvolensky, M. J. (2005). Distress tolerance and early smoking lapse. Clinical Psychology Review, 25(6), 713–733. doi: 10.1016/j.cpr.2005.05.003.PubMedCrossRefGoogle Scholar
  11. Buckner, J. D., Keough, M. E., & Schmidt, N. B. (2007). Problematic alcohol and cannabis use among young adults: The roles of depression and discomfort and distress tolerance. Addictive Behaviors, 32(9), 1957–1963. doi: 10.1016/j.addbeh.2006.12.019.PubMedCrossRefGoogle Scholar
  12. Burwell, R. A., & Shirk, S. R. (2007). Subtypes of rumination in adolescence: Associations between brooding, reflection, depressive symptoms, and coping. Journal of Clinical Child and Adolescent Psychology, 36(1), 56–65. doi: 10.1207/s15374424jccp3601_6.PubMedGoogle Scholar
  13. Caselli, G., Bortolai, C., Leoni, M., Rovetto, F., & Spada, M. M. (2008). Rumination in problem drinkers. Addiction Research & Theory, 16(6), 564–571. doi: 10.1080/16066350802100822.CrossRefGoogle Scholar
  14. Conway, M., Csank, P. R., Holm, S. L., & Blake, C. K. (2000). On assessing individual differences in rumination on sadness. Journal of Personality Assessment, 75(3), 404–425.PubMedCrossRefGoogle Scholar
  15. Cox, B. J., Enns, M. W., & Taylor, S. (2001). The effect of rumination as a mediator of elevated anxiety sensitivity in major depression. Cognitive Therapy and Research, 25(5), 525–534. doi: 10.1023/A:1005580518671.CrossRefGoogle Scholar
  16. Daughters, S. B., Lejuez, C. W., Bornovalova, M. A., Kahler, C. W., Strong, D. R., & Brown, R. A. (2005). Distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility. Journal of Abnormal Psychology, 114, 728–734. doi: 10.1037/0021-843X.114.4.729.CrossRefGoogle Scholar
  17. Daughters, S. B., Reynolds, E. K., MacPherson, L., Kahler, C. W., Danielson, C. K., Zvolensky, M., et al. (2009). Distress tolerance and early adolescent externalizing and internalizing symptoms: The moderating role of gender and ethnicity. Behaviour Research and Therapy, 47(3), 198–205. doi: 10.1016/j.brat.2008.12.001.PubMedCrossRefGoogle Scholar
  18. Dennhardt, A. A., & Murphy, J. G. (2011). Associations between depression, distress tolerance, delay discounting, and alcohol-related problems in European American and African American college students. Psychology of Addictive Behaviors, 25(4), 595–604. doi: 10.1037/a0025807.PubMedCrossRefGoogle Scholar
  19. Deyo, M., Wilson, K. A., Ong, J., & Koopman, C. (2009). Mindfulness and rumination: Does mindfulness training lead to reductions in the ruminative thinking associated with depression? Patient Education and Counseling, 5, 265–271.Google Scholar
  20. Ellis, A. J., Fischer, K. M., & Beevers, C. G. (2010). Is dysphoria about being red and blue? Potentiation of anger and reduced distress tolerance among dysphoric individuals. Cognition and Emotion, 24(4), 596–608. doi: 10.1080/13803390902851176.CrossRefGoogle Scholar
  21. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured clinical interview for DSM-IV-TR Axis I disorders, research version, patient edition with psychotic screen. New York: Biometrics Research, New York State Psychiatric Institute.Google Scholar
  22. Glick, D. M., & Orsillo, S. M. (2011). Relationships among social anxiety, self-focused attention, and experiential distress and avoidance. Journal of Cognitive and Behavioral Psychotherapies, 11(1), 1–12.Google Scholar
  23. Gorka, S. M., Ali, B., & Daughters, S. B. (2012). The role of distress tolerance in the relationship between depressive symptoms and problematic alcohol use. Psychology of Addictive Behaviors, 26(3), 621–626. doi: 10.1037/a0026386.PubMedCrossRefGoogle Scholar
  24. Harley, R., Sprich, S., Safren, S., Jacobo, M., & Fava, M. (2008). Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression. Journal of Nervous and Mental Disease, 196(2), 136–143. doi: 10.1097/NMD.0b013e318162aa3f.PubMedCrossRefGoogle Scholar
  25. Harrington, N. (2006). Frustration intolerance beliefs: Their relationship with depression, anxiety, and anger in a clinical population. Cognitive Therapy and Research, 30(6), 699–709. doi: 10.1007/s10608-006-9061-6.CrossRefGoogle Scholar
  26. Hasin, D., Liu, X., Nunes, E., McCloud, S., Samet, S., & Endicott, J. (2002). Effects of major depression on remission and relapse of substance dependence. Archives of General Psychiatry, 59(4), 375–380. doi: 10.1001/archpsyc.59.4.375.PubMedCrossRefGoogle Scholar
  27. Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76(4), 408–420. doi: 10.1080/03637750903310360.CrossRefGoogle Scholar
  28. Johnson, M. E., Neal, D. B., Brems, C., & Fisher, D. G. (2006). Depression as measured by the Beck Depression Inventory-II among injecting drug users. Assessment, 13(2), 168–177. doi: 10.1177/1073191106286951.PubMedCrossRefGoogle Scholar
  29. Just, N., & Alloy, L. B. (1997). The response styles theory of depression: Tests and an extension of the theory. Journal of Abnormal Psychology, 106(2), 221–229. doi: 10.1037/0021-843X.106.2.221.PubMedCrossRefGoogle Scholar
  30. Katz, E. J., & Bertelson, A. D. (1993). Effects of gender and response style on depressed mood. Sex Roles, 29(7–8), 509–514. doi: 10.1007/BF00289324.CrossRefGoogle Scholar
  31. Kross, E., Ayduk, O., & Mischel, W. (2005). When asking ‘why’ does not hurt: Distinguishing rumination from reflective processing of negative emotions. Psychological Science, 16(9), 709–715. doi: 10.1111/j.1467-9280.2005.01600.x.PubMedCrossRefGoogle Scholar
  32. Kuehner, C., & Weber, I. (1999). Responses to depression in unipolar depressed patients: An investigation of Nolen-Hoeksema's response styles theory. Psychological Medicine, 29(6), 1323–1333. doi: 10.1017/S0033291799001282.PubMedCrossRefGoogle Scholar
  33. Lejuez, C., Bornovalova, M., Daughters, S., & Curtin, J. (2005). Differences in impulsivity and sexual risk behavior among inner-city crack/cocaine users and heroin users. Drug and Alcohol Dependence, 77(2), 169–175.PubMedCrossRefGoogle Scholar
  34. Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psychopathological symptoms and disorders: A review of the empirical literature among adults. Psychological Bulletin, 136(4), 576–600.PubMedCrossRefGoogle Scholar
  35. Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. The American Journal on Addictions, 8(4), 279–292. doi: 10.1080/105504999305686.PubMedCrossRefGoogle Scholar
  36. MacPherson, L., Reynolds, E. K., Daughters, S. B., Wang, F., Cassidy, J., Mayes, L., et al. (2010). Positive and negative reinforcement underlying risk behavior in early adolescents. Prevention Science, 11(3), 331–342. doi: 10.1007/s11121-010-0172-7.PubMedCrossRefGoogle Scholar
  37. Martin, L. L., & Tesser, A. (1996). Some ruminative thoughts. In R. S. Wyer (Ed.), Ruminative thoughts (pp. 1–47). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.Google Scholar
  38. Mayer, J. D., & Salovey, P. (1997). What is emotional intelligence? In P. Salovey & D. J. Sluyter (Eds.), Emotional development and emotional intelligence: Educational implications (pp. 3–34). New York, NY: Basic Books.Google Scholar
  39. McIntosh, E., Gillanders, D., & Rodgers, S. (2010). Rumination, goal linking, daily hassles and life events in major depression. Clinical Psychology & Psychotherapy, 17(1), 33–43.Google Scholar
  40. McKay, J. R., Donovan, D. M., McLellan, T., Krupski, A., Hansten, M., Stark, K. D., et al. (2002). Evaluation of full vs. partial continuum of care in the treatment of publicly funded substance abusers in Washington State. The American Journal of Drug and Alcohol Abuse, 28(2), 307–338. doi: 10.1081/ADA-120002976.PubMedCrossRefGoogle Scholar
  41. McLaughlin, K. A., & Nolen-Hoeksema, S. (2011). Rumination as a transdiagnostic factor in depression and anxiety. Behaviour Research and Therapy, 49(3), 186–193. doi: 10.1016/j.brat.2010.12.006.PubMedCrossRefGoogle Scholar
  42. Michalak, J., Hölz, A., & Teismann, T. (2011). Rumination as a predictor of relapse in mindfulness-based cognitive therapy for depression. Psychology and Psychotherapy: Theory, Research and Practice, 84(2), 230–236. doi: 10.1348/147608310X520166.CrossRefGoogle Scholar
  43. Moulds, M. L., Kandris, E., Starr, S., & Wong, A. M. (2007). The relationship between rumination, avoidance and depression in a non-clinical sample. Behaviour Research and Therapy, 45(2), 251–261. doi: 10.1016/j.brat.2006.03.003.PubMedCrossRefGoogle Scholar
  44. Nezu, A. M., Ronan, G. F., Meadows, E. A., & McClure, K. S. (2000). Practitioner’s guide to empirically based measures of depression. Dordrecht Netherlands: Kluwer Academic Publishers.Google Scholar
  45. Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100(4), 569–582. doi: 10.1037/0021-843X.100.4.569.PubMedCrossRefGoogle Scholar
  46. Nolen-Hoeksema, S., & Girgus, J. S. (1994). The emergence of gender differences in depression during adolescence. Psychological Bulletin, 115(3), 424–443. doi: 10.1037/0033-2909.115.3.424.PubMedCrossRefGoogle Scholar
  47. Nolen-Hoeksema, S., & Harrell, Z. A. (2002). Rumination, depression, and alcohol use: Tests of gender differences. Journal of Cognitive Psychotherapy, 16(4), 391–403. doi: 10.1891/jcop.16.4.391.52526.Google Scholar
  48. Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61(1), 115–121. doi: 10.1037/0022-3514.61.1.115.PubMedCrossRefGoogle Scholar
  49. Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007). Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of Abnormal Psychology, 116(1), 198–207. doi: 10.1037/0021-843X.116.1.198.PubMedCrossRefGoogle Scholar
  50. Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 400–424. doi: 10.1111/j.1745-6924.2008.00088.x.CrossRefGoogle Scholar
  51. O’Cleirigh, C., Ironson, G., & Smits, J. J. (2007). Does distress tolerance moderate the impact of major life events on psychosocial variables and behaviors important in the management of HIV? Behavior Therapy, 38(3), 314–323. doi: 10.1016/j.beth.2006.11.001.PubMedCrossRefGoogle Scholar
  52. Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, 36, 717–731.CrossRefGoogle Scholar
  53. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891.PubMedCrossRefGoogle Scholar
  54. Raes, F. (2010). Ruminating and worrying as mediators of the relationship between self-compassion and anxiety and depression. Personality and Individual Differences, 48, 757–761.CrossRefGoogle Scholar
  55. Raes, F., & Hermans, D. (2008). On the mediating role of subtypes of rumination in the relationship between childhood emotional abuse and depressed mood: Brooding vs. Reflection. Depression & Anxiety, 25, 787–792.PubMedCrossRefGoogle Scholar
  56. Roberts, J. E., Gilboa, E., & Gotlib, I. H. (1998). Ruminative response style and vulnerability to episodes of dysphoria: Gender, neuroticism, and episode duration. Cognitive Therapy and Research, 22(4), 401–423. doi: 10.1023/A:1018713313894.CrossRefGoogle Scholar
  57. Roelofs, J., Muris, P., Huibers, M., Peeters, F., & Arntz, A. (2006). On the measurement of rumination: A psychometric evaluation of the ruminative response scale and the rumination on sadness scale in undergraduates. Journal of Behavior Therapy and Experimental Psychiatry, 37(4), 299–313. doi: 10.1016/j.jbtep.2006.03.002.PubMedCrossRefGoogle Scholar
  58. Sauer, S. E., & Baer, R. A. (2011). Ruminative and mindful self-focused attention in borderline personality disorder. Personality Disorders: Theory, Research, and Treatment. doi: 10.1037/a0025465.
  59. Saunders, J. B., Aasland, O. G., Babor, T. F., De La Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction, 88(6), 791–804.PubMedCrossRefGoogle Scholar
  60. Schmidt, N. B., Richey, J. A., Cromer, K. R., & Buckner, J. D. (2007). Discomfort intolerance: Evaluation of a potential risk factor for anxiety psychopathology. Behavior Therapy, 38, 247–255.PubMedCrossRefGoogle Scholar
  61. Schmidt, N. B., Richey, J., & Fitzpatrick, K. (2006). Discomfort intolerance: Development of a construct and measure relevant to panic disorder. Journal of Anxiety Disorders, 20(3), 263–280. doi: 10.1016/j.janxdis.2005.02.002.PubMedCrossRefGoogle Scholar
  62. Simons, J. S., & Gaher, R. M. (2005). The distress tolerance scale: Development and validation of a self-report measure. Motivation & Emotion, 29(2), 83–102. doi: 10.1007/s11031-005-7955-3.CrossRefGoogle Scholar
  63. Tate, S. R., Brown, S. A., Unrod, M., & Ramo, D. E. (2004). Context of relapse for substance-dependent adults with and without comorbid psychiatric disorders. Addictive Behaviors, 29(9), 1707–1724. doi: 10.1016/j.addbeh.2004.03.037.PubMedCrossRefGoogle Scholar
  64. Thase, M. E., Salloum, I. M., & Cornelius, J. D. (2001). Comorbid alcoholism and depression: Treatment issues. Journal of Clinical Psychiatry, 62(S20), 32–41.PubMedGoogle Scholar
  65. Trapnell, P. D., & Campbell, J. D. (1999). Private self-consciousness and the five-factor model of personality: Distinguishing rumination from reflection. Journal of Personality and Social Psychology, 76(2), 284–304. doi: 10.1037/0022-3514.76.2.284.PubMedCrossRefGoogle Scholar
  66. Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A psychometric analysis. Cognitive Therapy and Research, 27(3), 247–259. doi: 10.1023/A:1023910315561.CrossRefGoogle Scholar
  67. Watkins, E. (2004). Adaptive and maladaptive ruminative self-focus during emotional processing. Behaviour Research and Therapy, 42(9), 1037–1052. doi: 10.1016/j.brat.2004.01.009.PubMedCrossRefGoogle Scholar
  68. Watkins, E. R. (2008). Constructive and unconstructive repetitive thought. Psychological Bulletin, 134(2), 163–206. doi: 10.1037/0033-2909.134.2.163.PubMedCrossRefGoogle Scholar
  69. Watkins, E., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., et al. (2007). Rumination-focused cognitive behaviour therapy for residual depression: A case series. Behaviour Research and Therapy, 45(9), 2144–2154. doi: 10.1016/j.brat.2006.09.018.PubMedCrossRefGoogle Scholar
  70. Willem, L., Bijttebier, P., Claes, L., & Raes, F. (2011). Rumination subtypes in relation to problematic substance use in adolescence. Personality and Individual Differences, 50(5), 695–699. doi: 10.1016/j.paid.2010.12.020.CrossRefGoogle Scholar
  71. Zvolensky, M. J., Marshall, E. C., Johnson, K., Hogan, J., Bernstein, A., & Bonn-Miller, M. O. (2009). Relations between anxiety sensitivity, distress tolerance, and fear reactivity to bodily sensations to coping and conformity marijuana use motives among young adult marijuana users. Experimental and Clinical Psychopharmacology, 17(1), 31–42. doi: 10.1037/a0014961.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Jessica F. Magidson
    • 1
    • 2
  • Alyson R. Listhaus
    • 1
  • C. J. Seitz-Brown
    • 1
  • Katelyn E. Anderson
    • 1
  • Briana Lindberg
    • 1
  • Alexis Wilson
    • 1
  • Stacey B. Daughters
    • 3
  1. 1.Department of Behavioral and Community HealthUniversity of MarylandCollege ParkUSA
  2. 2.Department of PsychiatryMassachusetts General Hospital/Harvard Medical SchoolBostonUSA
  3. 3.Department of PsychologyUniversity of North CarolinaChapel HillUSA

Personalised recommendations