Validation of the Arabic versions of the long (15 items) and short (4 items) forms of the Distress Tolerance Scale (DTS)

doi:10.21203/rs.3.rs-4909439/v1

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Validation of the Arabic versions of the long (15 items) and short (4 items) forms of the Distress Tolerance Scale (DTS)

https://doi.org/10.21203/rs.3.rs-4909439/v1

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Background: Distress tolerance, defined as the capacity to endure and manage negative emotional states, is an important construct in comprehending various psychological conditions, including anxiety, depression, and substance use disorders. The Distress Tolerance Scale (DTS) and its Short Form (DTS-SF) are widely used tools for measuring distress tolerance. Still, their applicability in non-Western, Arabic-speaking populations has not been validated. Our study aims to examine the psychometric properties of an Arabic translation of the DTS and DTS-SF among Arabic-speaking general population adults.

Methods: A sample of 507 participants was recruited from diverse community settings. Participants completed the Arabic translations of the DTS and DTS-SF, alongside other relevant psychological measures, through an online survey. Confirmatory factor analysis (CFA) was used to evaluate the factor structure of both scales, and their reliability was assessed using McDonald’s omega and Cronbach’s alpha. Sex invariance was tested, and correlations with other psychological constructs, such as anxiety and child abuse, were examined to establish concurrent validity.

Results: CFA supported the four-factor structure of the DTS, especially after removing one item with low factor loading. Both the DTS and DTS-SF demonstrated strong internal consistency (DTS: ω = .91, α = .91; DTS-SF: ω = .77, α = .77) and good fit indices, confirming their reliability. Sex Invariance was established at the configural, metric, and scalar levels for both long and short versions. The DTS and DTS-SF scores showed significant correlations with anxiety and child abuse, supporting the scales' concurrent validity, while no significant correlation was found with pain, suggesting a differentiation between emotional distress and physical pain tolerance.

Conclusion: The study indicates that the Arabic versions of the DTS and DTS-SF are reliable and valid tools for assessing distress tolerance in Arabic-speaking populations. These scales are valuable for both clinical and research applications, enabling the identification of individuals at risk for psychological distress and guiding the development of culturally relevant interventions. Future research should explore the use of these psychometric instrument in other cultural contexts.

Distress Tolerance

Distress Tolerance Scale

Psychometric properties

Scale validation

Arabic

Distress tolerance is the ability to endure and manage negative emotional states, often leading to behaviors aimed at relief [1]. It is a meta-emotional construct with four dimensions: (1) tolerability and aversiveness, (2) appraisal and acceptability, (3) attention absorption and disruption, and (4) emotion regulation [1]. Distress tolerance is a higher-level concept that influences many elements of mood and behavior control. Gross (1998) identified five points for emotion regulation, categorizing them as four antecedent regulations and one response-oriented regulation [2]. The antecedent-focused regulating is manifested in approaches to selection and modification of the situations, attention deployment, and cognitive changes. The response-focused regulation involves managing emotional changes through behavior, such as suppressing emotion or using substances to dampen feelings. Distress tolerance influences the strategies used to manage affect and affects the regulation of behavior by emotional processes [1].

Distress tolerance is linked to the development and maintenance of psychopathological symptoms, such as substance use as an emotion-based coping strategy [3]. Moreover, the construct of distress tolerance has been used in reference to affect regulation. In Linehan’s Dialectic behavioral theory, this difficulty in tolerating distress stems from a mix of behavioral factors interacting with the social environment. This lack of tolerance can lead to perceiving distress as overwhelming, resulting in actions to ease the discomfort. Consequently, one’s ability to cope with distress greatly influences how emotions are regulated. Moreover, an individual’s resistance to accepting distress as a part of life can worsen their suffering by controlling how they interpret and respond to emotions [4]. This can make managing these emotions more challenging due to their perceived intensity and unpleasantness. Similarly, research on Acceptance and Commitment Therapy (ACT) underscores the impact of avoiding or suppressing emotions. ACT promotes acknowledging and embracing these emotions rather than pushing them suggesting that this approach offers valuable benefits for adaptation. It supports people in making changes, in their behavior by facing and dealing with emotions instead of ignoring them [5]. Moreover, Depression, pots-traumatic stress disorder (PTSD) [6], and eating disorders [7] are among the conditions that distress tolerance is associated with. Low distress tolerance has been observed in impulsive behaviors [8]. This construct is linked to factors such as ambiguity, intolerance of uncertainty, uneasiness, and frustration [9]. Considering these pertinent clinical implications, distress tolerance assessment can be significant in evaluating the risk of psychological difficulties in relevance to the inaptitude to manage negative emotional states, both before and during the treatment of various mental disorders.

Measurement of the distress tolerance construct

Limited evaluation techniques are available to examine the perceived capacity to manage emotionally distressing situations [10]. Measurement has usually focused on concepts linked to handling distress, such as avoiding experiences [11, 12]. Alternatively, studies have used experiments to see how long people endure emotionally challenging activities [13]. Moreover, the field of intelligence has delved into mood acceptance, nonetheless, this was not particularly focused on emotional distress [14]. One of the most widely recognized tools for evaluating distress tolerance is the Distress Tolerance Scale (DTS) created by Simons and Gaher [1], which was later shortened to only four items (i.e., the Distress Tolerance Scale-Short Form, DTS-SF) [15].

The 15-item DTS

It is composed of 15 items divided into four subscales, which are (1) appraisal of and acceptability of emotions (e.g., “My feelings of distress or being upset are not acceptable”), (2) the ability to tolerate negative emotional states (e.g., “Feeling distressed or upset is unbearable to me”), (3) absorption which explains the intensity of the attention an individual hold towards a negative emotion and how absorbing this state becomes (e.g., “My feelings of distress are so intense that they completely take over”) and (4) regulation which is the cognitive or behavioral strategy that individuals utilize to regulate themselves (e.g., “When I feel distressed or upset, I must do something about it immediately”) [1]. Each item can be rated on a 5-point scale ranging from 1 (Strongly agree) to 5 (Strongly disagree). Low scores represent low distress tolerance, while high scores represent high distress tolerance. Several studies have validated the four-factor domains and the psychometric properties of the DTS instrument [9, 16]. The higher-order scale showed good internal consistency (α = .82–.85), while the lower-order scales had adequate consistency (α = .70–.84) [1]. The 15-item DTS showed good convergent and discriminant validity. It was positively correlated with positive affectivity (r = .26) and negatively correlated with negative affectivity (r = − .59). It also showed significant positive correlations with negative mood regulation expectancies (r = .54) and general mood acceptance (r = .47), but less so with mood typicality (r = .17) [1]. Test-retest reliability of the 15-item DTS was supported, where over a six-month interval, the DTS showed temporal stability with an Interclass Correlation Coefficient of .61 [1]. Various studies have compared the DTS to assessment tools like the Discomfort Intolerance Scale (DIS; [17]) and physical stress tests linked to specific mental health conditions such as PTSD [18], as well as symptoms of anxiety and depression (Bernstein et al. 2011). Interestingly only the DTS showed correlations with disease severity, comorbidities, and overall quality of life in both these research studies [10].

The 4-item DTS-SF

Although the original 15-item DTS is a psychometrically solid tool for evaluating distress tolerance, there was a need for a shorter assessment tool, particularly in clinical settings as longer scales can lead to lower response quality [19]. To tackle this issue Garner and colleagues developed the DTS-SF [15]. They selected the highest loading items from each of the original DTS’s four subscales. The validity of the DTS SF was tested on individuals with obsessive-compulsive disorder (OCD) receiving inpatient treatment [15]. Furthermore, a subsequent study validated the DTS-SF in a sample of individuals with depressive symptoms, confirming its applicability across different clinical populations [20]. The DTS-SF demonstrated substantial associations with relevant measures and outcomes, demonstrating that lower DT was associated with increased symptom severity and worse quality of life. The DTS-SF also showed sensitivity to treatment effects, as participants scores notably improved during treatment sessions [15]. These results suggest that the DTS-SF is a valuable measure of distress tolerance.

The present study

This study intends to close the current gap by validating both the DTS and DTS-SF in a new language, nation, and non-Western Arabic-speaking cultural environment, which has not previously been explored, to better understand how this instrument operates in different cultural situations. Adults in the Arab world encounter several obstacles, including mental health issues, poor dietary habits, substance use and increasing exposure to violence, exacerbated by sociopolitical upheaval [21, 22]. Given these barriers, reliably assessing Distress Tolerance is critical not just for evaluating non-western adult’s mental health but also for implementing effective treatments. In this context, our study aims to examine the psychometric properties of an Arabic translation of the DTS and DTS-SF, expanding its usefulness and contributing to a better global understanding of distress tolerance in the Arab region. By accomplishing this, we hope to illuminate our understanding of how cultural differences impact the way Arabic-speaking adults endure and tolerate distress. It is expected that the Arabic translation of the DTS and DTS-SF will show good reliability and validity in a sample of Arabic speaking adults, demonstrating its strength and relevance across diverse cultural contexts.

Participants and procedure

This study has a cross-sectional design. The sample consisted of Arabic-speaking adults from the general population of Lebanon, aged over 18 years, and recruited from various community settings to ensure diversity in socio-demographic characteristics. Data were collected over the period of two months. Participants were invited to complete an online survey platform. Before participation, every participant was provided with detailed information about the study's purpose, procedures, and the voluntary nature of their involvement. They were assured of the confidentiality and anonymity of their responses. Informed consent was obtained from all participants before they began the survey. To account for order and sequence effects, the scales were distributed in a counterbalanced manner. There were no external incentives provided for participation in this research study.

Measures

The DTS

The DTS [1] is a self-report measure that assesses an individual's ability to tolerate emotional distress. Participants rate these items on a 5-point Likert scale rated from strongly agree (1) to strongly disagree (5). The DTS is scored by calculating the mean score for each subscale and/or obtaining a mean total score. Please note that question 6 requires reverse-coding. When evaluating DTS values, lower scores indicate a decreased ability to withstand negative emotions. The DTS and DTS-SF were translated from English to Arabic using a standardized translation method to ensure that the cultural context and language accuracy were maintained. Primarily, two bilingual professionals independently translated the scales into Arabic. A combined version of the two translations was produced with any discrepancies resolved through discussions among translators and experts in distress tolerance and psychological evaluation. The finalized Arabic version was then back-translated into English by translators who had not previously seen the original scales. This back translation was done to spot any inconsistencies or misinterpretations in the translation process.

The Short-Form McGill Pain Questionnaire (SF-MPQ) – Arabic version

The SF-MPQ is a checklist consisting of 15 items designed to evaluate both the sensory and affective aspects of pain [23]. The sensory dimension includes descriptors such as throbbing, shooting, stabbing, sharp, cramping, gnawing, hot-burning, aching, heavy, tender, and splitting, while the affective dimension covers tiring-exhausting, sickening, fearful, and punishing-cruel sensations. Each of these 15 items is rated on a four-point scale (0 indicating no pain, 1 representing mild pain, 2 for moderate pain, and 3 for severe pain). The scores from these items are combined to create separate sensory (11 items), affective (4 items), and total pain scores. Moreover, the questionnaire includes two additional items that assess the overall pain experience. Patients are asked to evaluate their current pain level using the Present Pain Intensity (PPI) index, where 1 corresponds to no pain, 2 to mild pain, 3 to discomfort, 4 to distressing pain, 5 to horrible pain, and 6 to excruciating pain. They are also asked to describe their pain as brief, intermittent, or continuous. Additionally, the SF-MPQ features a visual analog scale for further pain assessment. The Arabic- version of the questionnaire [24] has shown good reliability (α = .85), good test-retest reliability (r = 0.71), and construct validity.

The Generalized Anxiety Disorder-7 (GAD-7)

The GAD-7 is a self-reported questionnaire designed to evaluate anxiety levels over the past two weeks. It consists of 7 items, such as "Feeling nervous, anxious, or on edge," and uses a four-point Likert scale ranging from 0 ("Not at all") to 3 ("Nearly every day"). Higher scores reflect greater anxiety severity, with scores of 0–4 indicating no anxiety, 5–9 mild anxiety, 10–14 moderate anxiety, and 15 or more indicating severe anxiety symptoms. The questionnaire demonstrates satisfactory internal consistency, with Cronbach’s alpha ranging from 0.79 to 0.91, and has been validated for use among an Arabic-speaking Lebanese population [25].

The Child Abuse Self Report Scale (CASRS-12)

The CASRS-12 is a shortened version of the original 38-item Child Abuse Self Report Scale, designed to assess four core dimensions of child abuse: psychological abuse, physical abuse, sexual abuse, and neglect [26]. This tool was designed to provide a concise yet robust tool for measuring child abuse, especially in settings where the length of the original scale could lead to challenges in administration time and respondent participation. The CASRS-12 includes 12 carefully selected items, chosen based on their relevance and factor loadings from the original scale. Each dimension of abuse is represented by three items, providing comprehensive coverage of the constructs. Psychometric validation of the CASRS-12 was conducted among Arabic- speaking Lebanese adolescents, demonstrating strong internal consistency with McDonald’s omega values ranging from 0.87 to 0.93 across the four subscales. Both exploratory and confirmatory factor analyses supported a four-factor structure consistent with the original CASRS. The scale also showed adequate construct validity [26].

Analytic Strategy

Confirmatory factor analysis. There were no missing responses in the dataset. We used data from the total sample to conduct a CFA using the SPSS AMOS v.29 software. We aimed to enroll a minimum of 240 persons following the recommendations of Mundfrom et al. of 3 to 20 times the number of the scale’s variables [27]. Parameter estimates were obtained using the maximum likelihood method. Multiple fit indices were calculated: Steiger-Lind root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), Tucker-Lewis Index (TLI) and Comparative Fit Index (CFI). Values ≤ .08 for RMSEA, ≤ .05 for SRMR and ≥ .90 for CFI and TLI indicate good fit of the model to the data [28]. Multivariate normality was not verified at first (Bollen-Stine bootstrap p = .002); therefore we performed non-parametric bootstrapping procedure.

Sex invariance. To examine sex invariance of DTS scores, we conducted multi-group CFA [29] using the total sample. Measurement invariance was assessed at the configural, metric, and scalar levels [30]. We accepted ΔCFI ≤ .010 and ΔRMSEA ≤ .015 or ΔSRMR ≤ .010 as evidence of invariance [31]. Student t test was used to compare two means.

Composite reliability was assessed using McDonald’s ω and Cronbach’s α, with values greater than .70 reflecting adequate composite reliability. Normality was verified since the skewness and kurtosis values for each item of the scale varied between − 1 and + 1 [32]. Pearson test was used to correlate the DTS scores with the other scales.

Participants

Five hundred seven persons participated in this study, with a mean age of 26.80 ± 10.29 years, 73.2% females, 72.8% single and a mean HCI of 1.14 ± .55 persons/room.

Confirmatory Factor Analysis

CFA indicated that fit of the four-factor model of the DTS long form scale was acceptable: RMSEA = .063 (90% CI .054, .072), SRMR = .045, CFI = .949, TLI = .937. We noticed that the loading factor of item 6 was low (< .33), and was consequently removed. The fit indices of the new model improved: RMSEA = .058 (90% CI .049, .068), SRMR = .035, CFI = .962, TLI = .951. The standardized estimates of factor loadings are summarized Figs. 1 and 2. Composite reliability of scores were as follows: Factor 1 (ω = .77 / α = .77), Factor 2 (ω = .80 / α = .78), Factor 3 (ω = .78 / α = .77), Factor 4 (ω = .77 / α = .77), and the total score (ω = .91 / α = .91).

The fit indices of the second order model were adequate too: RMSEA = .063 (90% CI .054, .073), SRMR = .040, CFI = .954, TLI = .943.

The fit indices of the DTS-SFwere adequate: RMSEA = .088 (90% CI .038, .146), SRMR = .024, CFI = .985, TLI = .955. The standardised estimates of factor loadings are summarized Fig. 3. Composite reliability was good (ω = .77 / α = .77).

Sex Invariance

We were able to show the invariance of the long and short forms of the DTS scale across sex at the configural, metric, and scalar levels (Table 1). No significant difference was found between males and females in terms of DTS (38.78 ± 12.83 vs 38.71 ± 10.74; t(505) = .06; p = .951) and DTS-SF (10.10 ± 3.95 vs 10.28 ± 3.37; t(505) = − .46; p = .647) scores.

Table 1

*Measurement Invariance of the Distress Tolerance Scale (DTS) and Distress Tolerance Scale-Short Form (DTS-SF) across sex.*
Model	CFI	RMSEA	SRMR	Model Comparison	ΔCFI	ΔRMSEA	ΔSRMR
a) DTS
Configural	.939	.049	.054
Metric	.938	.048	.065	Configural vs metric	.001	.001	.011
Scalar	.936	.047	.066	Metric vs scalar	.002	.001	.001
b) DTS-SF
Configural	.985	.062	.007
Metric	.985	.046	.022	Configural vs metric	< .001	.016	.015
Scalar	.984	.040	.024	Metric vs scalar	.001	.006	.002
Note. CFI = Comparative fit index; RMSEA = Steiger-Lind root mean square error of approximation; SRMR = Standardised root mean square residual.

Concurrent validity

Higher anxiety and childhood abuse, but not bodily pain, were significantly associated with higher DTS and DTS-SF scores (Table 2).

Table 2

Pearson correlation matrix.
	Mean ± SD	1	2	3	4
1. DTS	38.73 ± 11.32	1
2. DTS-SF	10.23 ± 3.53	.91***	1
3. Bodily pain	12.08 ± 9.84	− .03	− .04	1
4. Anxiety	7.52 ± 4.93	− .13**	− .15**	.53***	1
5. Child abuse	8.05 ± 6.61	− .10*	− .08	.43***	.30***

*p < .05; **p < .01; ***p < .001; DTS LF = Distress Tolerance Scale Long Form; DTS SF = Distress Tolerance Scale Short Form.

The primary objective of this study was to assess the reliability and validity of the DTS and its short version (DTS-SF) in a non- western, Arabic- speaking population. The study sough to verify that these psychometric tools reliably gauge distress tolerance in Arabic speaking adults taking into account cultural nuances. The study’s results support the reliability and validity of the Arabic versions of the DTS when administered to Arabic-speaking community adults.

The confirmatory factor analysis (CFA) showed that the four-factor structure of the DTS had good fit indices, especially after removing item 6 due to its low factor loading (< .33). These results align with previous studies demonstrating the scale’s strong internal reliability and model fit for the DTS in other cultural contexts [10, 20]. The composite reliability values for the DTS were high, reflected by McDonald’s ω (.91) and Cronbach’s α (.91). This adequate level of internal consistency demonstrates that the DTS is a reliable assessment instrument of distress tolerance among Arabic-speaking adults, in consensus with other research, including studies from Australia (DTS total α = 0.92, ω = 0.92; [20]) and Italy (total α = 0.91, ω = 0.92; [10]). The DTS-SF also demonstrated acceptable fit indices. The composite reliability for the DTS-SF was ω = .77, α = .77, indicating adequate reliability. This is consistent with findings by Garner et al. (2018) [15], which highlighted the DTS-SF's reliability in clinical settings, emphasizing its applicability in situations where brevity is required.

The study demonstrated that both the DTS and DTS-SF are invariant across sex at the configural, metric, and scalar levels, suggesting that these scales measure distress tolerance equivalently in males and females. This aligns with the findings of Garner et al. (2018) [15] and Melli et al. (2021) [10], who also established sex invariance in their analyses, reinforcing the scales' robustness in diverse populations. While the scales are invariant, the analysis of DTS scores did not reveal significant sex differences, which is in alignment with other studies like Brown et al. (2022) [20] that also found no notable gender-based disparities in distress tolerance levels. This suggests that distress tolerance as a construct is not inherently gender-biased in its measurement

The DTS scores correlated as expected with relevant psychological constructs, namely anxiety and child abuse. These correlations are consistent with literature findings that show distress tolerance is associated with other psychological outcomes, indicating good concurrent validity (Garner et al., 2018) [15]. This implies that the DTS is valuable not just for measuring distress tolerance, but also for pinpointing individuals susceptible to associated mental health challenges, thereby assisting in crafting specific interventions. However, no significant correlation was found with pain, indicating it may not be directly related to distress tolerance as measured by the DTS. This suggests that although the DTS is good at gauging emotional and psychological distress tolerance, it might not fully capture how individuals handle physical pain. The absence of a connection could show a difference between dealing with emotional distress and physical discomfort, indicating that the ways people cope with these various types of distress could be quite different. Future studies could delve into this difference, possibly by incorporating more targeted assessments for pain tolerance or by investigating how distress tolerance relates to various physical and emotional challenges.

Theoretical and Practical Implications

The results add to the literature supporting the applicability of the distress tolerance construct in a new cultural context [10, 15, 20]. Practically, the validated DTS can help clinicians and researchers assess distress tolerance in Arabic-speaking adults, which is critical for mental health interventions and research. Validating the DTS and its Short Form in Arabic-speaking communities demonstrates the scales' adaptability across cultures. This supports the concept of distress tolerance as a universal construct that can be measured in diverse populations. The DTS, characterized by its four-factor structure and high overall reliability provides an evaluation that captures the diverse facets of distress tolerance supporting its cross-cultural validity. On the other hand, the DTS- SF exhibits good psychometric properties, thus serving as a convenient and efficient tool for swift assessments. The DTS is suited for in depth evaluations while the DTS-SF is more appropriate for screenings and large-scale studies thereby enhancing health assessments and interventions tailored to Arabic speaking adults.

Limitation and future research

Despite the significant findings, our study has some limitations. Mainly young adults (with an average age of 26.80 years) and females (73.2%) were involved, which may restrict how broadly we can apply the findings to different age groups and a more equal representation of sexes. Relying on self-reported data can introduce biases like social desirability and inaccuracies in self-assessment. Selection bias is possible because of the convenient sampling and the unknown response rate. While the study assessed convergent validity concerning anxiety and child abuse, it did not include important psychological factors, like depression, stress and coping strategies. Future research should encompass a range of variables to fully validate both convergent and discriminant validity of the scale.

This research study confirmed the accuracy of the DTS and DTS-SF, proving their reliability and suitability in the Arabic-speaking context. These scales support the creation of health interventions by identifying people with low distress tolerance, enabling professionals to tailor techniques for enhancing coping mechanisms and minimizing maladaptive behaviors. Additionally, this contributes to the progress of research on the significance of distress tolerance, which assists in developing effective therapeutic methods. Future research should focus on applying these tools in various cultural contexts and longitudinal studies to deepen our understanding of distress tolerance and enhance emotional resilience worldwide.

Ethics Approval and Consent to Participate.

The Lebanese International University's School of Pharmacy ethics committee granted this study ethics permission. When filling out the online form, each participant provided written informed consent, as did their parents or legal guardian(s) if they were study participants under the age of sixteen. All methods were performed in accordance with the relevant guidelines and regulations (in accordance with the Declaration of Helsinki).

Consent for publication:

Not applicable.

Competing interests:

The authors have nothing to disclose.

Funding:

None.

Author Contribution

SO, SH and FFR designed the study; AN drafted the manuscript; SH carried out the analysis and interpreted the results; FS and MD collected the data. DM and TS reviewed the paper for intellectual content; all authors reviewed the final manuscript and gave their consent.

Acknowledgement

The authors would like to thank all participants.

Data Availability

Because of ethical committee constraints, none of the data collected or analyzed during this study are publicly available. However, the corresponding author (SH) may make the data available upon reasonable request.

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No competing interests reported.

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Validation of the Arabic versions of the long (15 items) and short (4 items) forms of the Distress Tolerance Scale (DTS)

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Abstract

Figures

Introduction

Measurement of the distress tolerance construct

The 15-item DTS

The 4-item DTS-SF

The present study

Methods

Participants and procedure

Measures

The DTS

The Short-Form McGill Pain Questionnaire (SF-MPQ) – Arabic version

The Generalized Anxiety Disorder-7 (GAD-7)

The Child Abuse Self Report Scale (CASRS-12)

Analytic Strategy

Results

Participants

Confirmatory Factor Analysis

Sex Invariance

Concurrent validity

Discussion

Theoretical and Practical Implications

Limitation and future research

Conclusion

Declarations

Competing interests:

Funding:

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

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