Distress tolerance predicts coping motives for marijuana use among treatment seeking young adults

Distress tolerance predicts coping motives for marijuana use among treatment seeking young adults

Addictive Behaviors 58 (2016) 85–89 Contents lists available at ScienceDirect Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbe...

263KB Sizes 36 Downloads 3224 Views

Addictive Behaviors 58 (2016) 85–89

Contents lists available at ScienceDirect

Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh

Short Communication

Distress tolerance predicts coping motives for marijuana use among treatment seeking young adults Stephen Semcho a,⁎, Sarah A. Bilsky b, Sarah F. Lewis a, Ellen W. Leen-Feldner b a b

Center for Research, Assessment, and Treatment Efficacy (CReATE), Asheville, NC, United States Department of Psychological Science, University of Arkansas, Fayetteville, AR, United States

H I G H L I G H T S • Coping related motives for marijuana use enhance risk for marijuana use problems • We examined the relation between distress tolerance and coping motives for marijuana use in treatment seeking young adults • Distress tolerance is related to coping motives for marijuana use over and above theoretically relevant covariates

a r t i c l e

i n f o

Article history: Received 28 July 2015 Received in revised form 5 February 2016 Accepted 9 February 2016 Available online 10 February 2016 Keywords: Marijuana Distress tolerance Coping motives Treatment Young adults

a b s t r a c t Given increasing marijuana use and abuse among young adults in the United States and the associated physical and mental health consequences, it is important to improve our understanding of factors that may contribute to problematic marijuana use. A convergence of theory and research underscores the relevance of particular marijuana use motives generally, and coping-related motives specifically, in enhancing risk for marijuana use problems. Distress tolerance is a transdiagnostic emotion vulnerability factor that may relate to coping-related motives for marijuana use. The current study was designed to further explore this relationship within a treatment-seeking sample of young adults (Mage = 24.40; SD = 2.06 years). Results were consistent with hypotheses, suggesting distress tolerance is related to coping motives for marijuana use within this treatmentseeking sample, even after accounting for a number of theoretically relevant covariates. Theoretical and applied implications of distress tolerance as it relates to coping motives for marijuana use as treatment targets are discussed. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction Marijuana use and abuse among young adults are increasing in the US (Compton, Grant, Colliver, Glantz, & Stinson, 2004) with 20% of young adults reporting past-month marijuana use (Johnston, O'Malley, Bachman, Schulenberg, & Miech, 2014). These data are troubling given that marijuana use is associated with adverse physical (Caldeira, O'Grady, Vincent, & Arria, 2012) and mental health (Rey, Sawyer, Raphael, Patton, & Lynskey, 2002) outcomes. It is important to improve our understanding of factors that may contribute to marijuana use among young adults. Theoretical perspectives emphasize motivational processes in marijuana use (Zvolensky et al., 2009), and suggest distinct motives for substance use may be predictive of problematic use trajectories (Cooper, 1994). Motives are considered proximal determinants of ⁎ Corresponding author at: Center for Research, Assessment and Treatment Efficacy, 14 S. Pack square, Suite # 505, Asheville, NC 28801, United States. E-mail address: [email protected] (S. Semcho).

http://dx.doi.org/10.1016/j.addbeh.2016.02.016 0306-4603/© 2016 Elsevier Ltd. All rights reserved.

substance use that often mediate the pathway between more distal risk factors (e.g., dysregulated anger, Mischel et al., 2014) and substance use (Cooper, 1994). Researchers have identified five motives for marijuana use: coping (e.g., “to help me forget my worries”), enhancement (e.g., “I use marijuana to get high”), conformity (e.g., “to fit in with the group I like”), expansion (e.g., “because it helps me be more creative and original”), and social (e.g., “to be sociable;” Simons, Correia, Carey, & Borsari, 1998). Specific motives relate to past month marijuana use in young adults, over and above theoretically relevant covariates (Bonn-Miller, Zvolensky, & Bernstein, 2007b; Bonn-Miller, Vujanovic, Feldner, Bernstein, & Zvolensky, 2007a). Coping-related motives appear to be particularly relevant to problematic marijuana use (Bonn-Miller & Zvolensky, 2009), in part due to their likely role in co-occurring marijuana use and clinical symptomatology. Consistent with tension reduction models of substance use (Conger, 1956), individuals may use marijuana to decrease commonly co-occurring negative affective states (e.g., anxiety, depression; Buckner, Joiner, Schmidt, & Zvolensky, 2012a; Ketcherside & Filbey, 2015; Van Dam, Bedi, & Earleywine, 2012). Evidence suggests marijuana users report increased use during times of


S. Semcho et al. / Addictive Behaviors 58 (2016) 85–89

affective distress (Kaplan, Martin, Johnson, & Robbins, 1986), and coping-related motives mediate the relation between anxiety-relevant symptoms and marijuana use (e.g., Buckner, Zvolensky, & Schmidt, 2012b; Potter, Vujanovic, Marshall-Berenz, Bernstein, & Bonn-Miller, 2011). Collectively, these data underscore the significance of improving our understanding of coping motives and factors that may increase the likelihood of using marijuana for coping-related reasons. It stands to reason that individuals with transdiagnostic emotion vulnerability factors may be at increased risk for using marijuana to mitigate negative affective states. One such factor is distress tolerance, conceptualized as the perceived ability and behavioral act of tolerating negative psychological and physiological states (Leyro, Zvolensky, & Bernstein, 2010; Simons & Gaher, 2005). Emotion regulation among individuals low in distress tolerance is characterized by efforts to avoid or quickly alleviate negative states (Wolitzky-Taylor et al., 2015). Distress tolerance is considered a malleable factor (Brown et al., 2014; Linehan, 1993) that evidences robust negative associations with multiple types of substance use, including marijuana (Bujarski, Norberg, & Copeland, 2012). Indeed, previous work with community samples suggests distress tolerance evidences a unique relation with coping motives for marijuana use (Zvolensky et al., 2009). Absent from the literature is an analysis of distress tolerance as it relates to coping motives for marijuana use among treatment-seeking young adults, despite data linking such motives to elevated marijuana use within this population (Norberg, Olivier, Schmidt, & Zvolensky, 2014). This is noteworthy, given young adults are more than twice as likely as adults in other age groups to receive a substance use disorder diagnosis (Substance Abuse and Mental Health Services Administration; SAMHSA, 2014). Indeed, young adults in substance use treatment tend to have high levels of psychiatric co-morbidity (Chan, Dennis, & Funk, 2008; Marsden, Gossop, Stewart, Rolfe, & Farrell, 2000), which in turn is associated with more problematic cannabis use (Brook, Lee, Brown, & Finch, 2012; Buckner et al., 2008). While mental health disorders are prominent in young adults, treatment seeking is relatively rare. For example, one study suggested almost half (47%) of college students meet criteria for a past year mental health disorder, including substance use disorders, but only 20% sought mental health services (Blanco et al., 2008). This suggests that treatment seeking young adults may have unique features that are absent in their same-age cohorts struggling with mental health issues, and underscores the importance of extending our study of coping-related marijuana use motives to this population. The current study was designed to extend the existing literature by examining the association between distress tolerance and coping motives for marijuana use within a treatment-seeking sample of young adults. To provide a conservative test of study hypotheses, the incremental predictive validity of distress tolerance in predicting copingrelated motives was evaluated after accounting for individual differences in the general tendency to experience negative affectivity. It was hypothesized that distress tolerance would evidence a specific association with coping motives for marijuana use. The association between distress tolerance and enhancement motives was also evaluated. Although enhancement motives are linked to increased marijuana use (Bonn-Miller et al., 2007a, 2007b), they are characterized by a desire to enhance positive social and emotional experiences (Simons et al., 1998), rather than to cope with aversive emotional experiences. Therefore, no significant effects of distress tolerance on enhancement motives for marijuana use were expected. 2. Method 2.1. Participants One hundred and eight participants (22 females) were drawn from a larger (n = 296), prospective study of treatment-seeking young adults

(Mage = 24.40; SD = 2.06) enrolled in residential treatment for substance use disorders (SUD). The sample was predominantly Caucasian (94.5%) and 93% reported clinically significant symptoms of SUDs at baseline, with alcohol and marijuana being the most frequently used substances (see Table 1). Participants were selected for current analyses if they reported current (i.e., past-month) marijuana use (Kraus, Seligman, & Jordan, 2005) at baseline (i.e., upon treatment program admission). 2.2. Measures The well-established Treatment Outcome Package, supplemental Drug and Alcohol Scale (TOP; Kraus et al., 2005) was used to index frequency and severity of marijuana use. Negative affective intensity and reactivity were indexed using the Affect Intensity Measure (AIM; Larsen, 1984). Participants rate 40 items using a 1 (Never) to 6 (Always) scale. Factor analyses suggest the AIM is comprised of three subfactors reflecting response to positive and negative affective states and stimuli (Bryant, Yarnold, & Grimm, 1996). Only the Negative Intensity (AIM-NI; “When I am nervous I get shaky all over”) and Negative Reactivity (AIM-NR; “When I do something wrong I have strong feelings of shame and guilt”) were deemed conceptually relevant to study hypotheses and utilized here. The AIM has excellent psychometric properties (current study α = 0.70 and .75 for the AIM-NR and AIM-NI subscales; Larsen, Diener, & Emmons, 1986). The 15-item Distress Tolerance Scale (DTS; Simons & Gaher, 2005) was employed to index distress tolerance. Participants rate items such as “I can't handle feeling distressed or upset” on a 5-point scale (1 = Strongly agree to 5 = Strongly disagree). The DTS is a psychometrically sound instrument (current sample α = .93). The 25-item Marijuana Motives Measure (MMM; Simons et al., 1998) indexes frequency of use with respect to specific motives (e.g., “to forget my worries”) using a 5-point scale (1 = Almost never/never to 5 = Almost always/always). The MMM evidences good construct validity (Simons et al., 1998; current sample α = 0.78–0.88). 2.3. Procedure After participants provided written informed consent, questionnaires were completed in a private space with a researcher available to answer questions. 3. Results Hierarchical regression analysis was utilized to address study hypotheses. AIM-NI and NR scores were entered at step 1, non-criterion marijuana use motives at step 2, and DTS scores at step 3, allowing for an evaluation of the incremental validity of DTS scores in predicting either MMM-coping (Model 1) or MMM-enhancement (Model 2) scores. Effect size was indexed using sr2. Table 1 includes variable means, standard deviations, and inter-correlations. Regression analyses are presented in Table 2. In Model 1, AIM-NI and NR scores accounted for 2.2% of the variance in MMM-coping scores, although neither reached statistical significance. At step 2, MMM-social (sr2 = .11, p b .001) and MMMenhancement (sr2 = .06, p b .001) scores were significant predictors. Finally, at step 3, DTS scores were significantly associated with MMMcoping scores (ΔR2 = .05; β = −.31; sr2 = .05, p = .001); as distress tolerance decreased, endorsement of coping-related motivations for marijuana use increased. In the second model, AIM-NR and NI scores were not significantly associated with MMM-enhancement scores at step 1. At step 2, MMMsocial (sr2 = .04, p b .01), MMM-coping (sr2 = .07, p b .001), and MMM-conformity (sr2 = .06, p = .001) scores were significant predictors. As predicted, DTS scores did not account for significant variance in

S. Semcho et al. / Addictive Behaviors 58 (2016) 85–89


Table 1 Sample characteristics. Marijuana use frequency, other substance use, and comorbid conditions Age of 1st MJ use

Years of Age of onset for daily MJ use daily MJ use


Tobacco Cocaine


Halluci nogens

Amphetamines Opiates Over-the-counter medications

14.72 (1.83) –

5.14 (5.29)

16.14 (3.21)

Frequency of past month use (%) Disorder – Participants – meeting criteria (%) TOP factor domains –









– –

– –

Depression Mania 46.7% 11.4%

SI 22.1%

Panic 38.1%

– –

– –

– –

– –

Panic Psychotic symptoms symptoms 1.38 1.56

Suicidality –

Depression Quality of life 1.92 2.14

Mean (SD)

Mean TOP z-score


Descriptive data and zero-order correlations among theoretically relevant variables Mean (SD) 1. Age (years) 2. AIM-NR 3. AIM-NI 4. MMM-social 5. MMM-conformity 6. MMM-expansion 7. MMM-enhancement 8. MMM-coping 9. DTS

24.40 (2.06) 3.43 (0.80) 3.21 (0.86) 3.00 (1.05) 1.57 (0.72) 2.70 (1.13) 4.07 (0.81) 3.48 (1.12) 3.06 (1.01)










.15 –

.07 .53⁎⁎⁎ –

−.09 .03 −.02 –

.06 .12 .11 .25⁎⁎

−.08 .01 .01 .43⁎⁎⁎

−.18 −.14 −.18 .52⁎⁎⁎

−.07 .14 .12 .66⁎⁎⁎

−.10 −.33⁎⁎⁎ −.53⁎⁎⁎

.00 –

−.16 .35⁎⁎⁎ –

.14 .40⁎⁎⁎ .54⁎⁎⁎ –

−.10 −.16 −.19⁎ −.02 −.35⁎⁎⁎ –

Note. n = 108. AIM: Affective Intensity Measure (NR — Negative Reactivity, NI — Negative Intensity), DTS: Distress Tolerance Scale, MJ: Marijuana, MMM: Marijuana Motives Measure, SI: Suicidal Ideation, TOP: Treatment Outcome Package. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

MMM-enhancement scores after accounting for covariates (ΔR2 = .00; β = .01; sr2 = .00). 4. Discussion Coping motives for marijuana use are linked with increased risk for marijuana use problems (Bonn-Miller & Zvolensky, 2009), and appear to play a mediating role in co-occurring marijuana use and internalizing disorders (Buckner et al., 2012a, 2012b; Johnson et al., 2009). Improving our understanding of malleable affective vulnerability factors, such as distress tolerance, that relate to coping motives for marijuana use is important for advancing our ability to address marijuana-related problems. The current study was designed to extend prior work linking distress tolerance to coping motives for marijuana use by evaluating this relation within a treatment-seeking sample of young adults. Given the unique characteristics of treatment-seeking young adults, this represents an important advance on our current knowledge. Consistent with hypotheses, distress tolerance related negatively to coping-related motives for marijuana use. These data comport with previous findings (Zvolensky et al., 2009) and suggest that the inability to manage distress elicited by aversive states is associated with marijuana use to cope. Notably, distress tolerance was uniquely associated with coping motives above and beyond covariates, including a general tendency toward negative affectivity and other motives for marijuana use (see Table 2; Buckner, Bonn-Miller, Zvolensky, & Schmidt, 2007). This effect size was small, but was consistent with published work in the area and notable given variance accounted for by factors at earlier steps in the model. Finally, evidence of specificity was obtained; as expected, distress tolerance was not related to enhancement motives. These findings extend the empirical literature by providing a test of the relation between distress tolerance and coping-related motives among treatment-seeking young adults. From a clinical perspective, it is well-established that various aspects of the substance use process,

including craving and withdrawal, as well as symptoms of commonly co-occurring psychological disorders, can contribute to drug administration (e.g., Goldstein & Volkow, 2011). Recent work targeting distress tolerance in the context of tobacco cessation further suggests that teaching users to withstand such negative states may improve abstinence efforts (Brown et al., 2013). The current findings suggest that distress tolerance may similarly serve as a useful treatment target for copingrelated marijuana use among treatment seekers. While this is an important contribution, a number of limitations warrant mention. First, the current cross-sectional study design

Table 2 Regression analyses: distress tolerance scores predicting motives for marijuana use. MMM-coping 2


MMM-enhancement 2



.16 .08

.01 .00

.49 .09 .09 .47 –

.11⁎⁎⁎ .00 .01 .06⁎⁎⁎ –




Step 1 AIM NR AIM NI Step 2 MMM-social MMM-conformity MMM-expansion MMM-enhancement MMM-coping Step 3 DTS






−.06 −.14

.00 .02

.23 −.29 .06 – .26

.04⁎⁎ .06⁎⁎⁎ .01 – .07⁎⁎⁎






Note. n = 108. β = standardized beta weight. AIM: Affective Intensity Measure (NR — Negative Reactivity, NI — Negative Intensity), DTS: Distress Tolerance Scale, MMM: Marijuana Motives Measure, MMM-Enhancement scores were the criterion variable in the first model; MMM-coping scores were the criterion variable in second model. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.


S. Semcho et al. / Addictive Behaviors 58 (2016) 85–89

precludes inferences about causality and directionality. Future work involving experimental manipulation of distress tolerance (e.g., mirror tracing; Leyro et al., 2010) or adaptation of applied distress tolerance interventions (Brown et al., 2008) would allow for causal tests of the prospective effects of distress tolerance on marijuana use motives and potentially inform related intervention efforts. A laboratory-based approach would also attenuate recall and affective biases introduced by exclusive reliance on self-report assessment (Nisbett & Ross, 1980). Finally, the sample was comprised of primarily Caucasian participants. A number of factors, including psychiatric symptoms, affective intensity or reactivity, and substance use frequency, may serve as moderators of the relation between distress tolerance and marijuana use. Exploring these factors in larger and more diverse samples represents an important future research step. These limitations notwithstanding, the current study represents a valuable extension to the literature, suggesting distress tolerance evidences a unique and specific association with coping-related motives for marijuana use among treatment seeking young adults. These results underscore the importance of considering factors such as distress tolerance vis-à-vis substance use motives in the treatment context. Role of funding sources This material is based, in part, upon work supported by the National Science Foundation Graduate Research Fellowship Program under Grant No. 2015179871 awarded to Sarah A. Bilsky. Contributors All authors have contributed significantly to the paper and have approved the final manuscript. Specifically, the first author (S. Semcho) wrote the manuscript, conducted literature searches, conducted statistical analyses, and compiled portions of the reference section. The second author (S. Bilsky) wrote portions of the manuscript, conducted literature searches, assisted in statistical analyses, and compiled portions of the reference section and tables. The third author (S. Lewis) was involved in the project design, contributed to writing the method section, and consulted on data analysis. The fourth author (E. Leen-Feldner) assisted in statistical analysis and assisted in writing the manuscript. All authors contributed to, edited, and approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest. Acknowledgments The authors would like to thank the study participants, Aspen Education Group, CRC, and several key research personnel, including Dr. Sheneen Daniels and Alex Pena, without whom this study could not have been completed.

References Blanco, C., Okuda, M., Wright, C., Hasin, D.S., Grant, B.F., Liu, S.M., & Olfson, M. (2008). Mental health of college students and their non-college-attending peers: Results from the national epidemiologic study on alcohol and related conditions. Archives of General Psychiatry, 65, 1429–1437. Bonn-Miller, M.O., & Zvolensky, M.J. (2009). An evaluation of the nature of marijuana use and its motives among young adult active users. American Journal on Addictions, 18 (5), 409–416. Bonn-Miller, M.O., Vujanovic, A.A., Feldner, M.T., Bernstein, A., & Zvolensky, M.J. (2007a). Posttraumatic stress symptom severity predicts marijuana use coping motives among traumatic event-exposed marijuana users. Journal of Traumatic Stress, 20(4), 577–586. http://dx.doi.org/10.1002/jts.20243. Bonn-Miller, M.O., Zvolensky, M.J., & Bernstein, A. (2007b). Marijuana use motives: Concurrent relations to frequency of past 30-day use and anxiety sensitivity among young adult marijuana smokers. Addictive Behaviors, 32(1), 49–62. Brook, J.S., Lee, J.Y., Brown, E.N., & Finch, S.J. (2012). Comorbid trajectories of tobacco and marijuana use as related to psychological outcomes. Substance Abuse, 33(2), 156–167. http://dx.doi.org/10.1080/08897077.2011.640202. Brown, R.A., Palm, K.M., Strong, D.R., Lejuez, C.W., Kahler, C.W., Zvolensky, M.J., ... Gifford, E.V. (2008). Distress tolerance treatment for early-lapse smokers: Rationale, program description, and preliminary findings. Behavior Modification, 32, 302–332. http://dx. doi.org/10.1177/0145445507309024. Brown, R.A., Reed, K.P., Bloom, E.L., Minami, H., Strong, D.R., Lejuez, C.W., ... Hayes, S.C. (2013). Development and preliminary randomized controlled trial of a distress tolerance treatment for smokers with a history of early lapse. Nicotine & Tobacco Research, 15(12), 2005–2015. http://dx.doi.org/10.1093/ntr/ntt093. Brown, R.A., Bloom, E.L., Hecht, J., Moitra, E., Herman, D.S., & Stein, M.D. (2014). A pilot study of a distress tolerance treatment for opiate-dependent patients initiating buprenorphine: Rationale, methodology, and outcomes. Behavior Modification, 38 (5), 730–759. http://dx.doi.org/10.1177/0145445514538279.

Bryant, F.B., Yarnold, P.R., & Grimm, L.G. (1996). Toward a measurement model of the affect intensity measure: A three-factor structure. Journal of Research in Personality, 30(2), 223–247. Buckner, J.D., Bonn-Miller, M.O., Zvolensky, M.J., & Schmidt, N.B. (2007). Marijuana use motives and social anxiety among marijuana-using young adults. Addictive Behaviors, 32(10), 2238–2252. http://dx.doi.org/10.1016/j.addbeh.2007.04.004. Buckner, J.D., Schmidt, N.B., Lang, A.R., Small, J.W., Schlauch, R.C., & Lewinsohn, P.M. (2008). Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence. Journal of Psychiatric Research, 42(3), 230–239. Buckner, J.D., Joiner, T.J., Schmidt, N.B., & Zvolensky, M.J. (2012a). Daily marijuana use and suicidality: The unique impact of social anxiety. Addictive Behaviors, 37(4), 387–392. http://dx.doi.org/10.1016/j.addbeh.2011.11.019. Buckner, J.D., Zvolensky, M.J., & Schmidt, N.B. (2012b). Cannabis-related impairment and social anxiety: The roles of gender and cannabis use motives. Addictive Behaviors, 37 (11), 1294–1297. Bujarski, S.J., Norberg, M.M., & Copeland, J. (2012). The association between distress tolerance and cannabis use-related problems: The mediating and moderating roles of coping motives and gender. Addictive Behaviors, 37(10), 1181–1184. Caldeira, K.M., O'Grady, K.E., Vincent, K.B., & Arria, A.M. (2012). Marijuana use trajectories during the post-college transition: Health outcomes in young adulthood. Drug and Alcohol Dependence, 125(3), 267–275. http://dx.doi.org/10.1016/j.drugalcdep.2012. 02.022. Chan, Y., Dennis, M.L., & Funk, R.R. (2008). Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment. Journal of Substance Abuse Treatment, 34(1), 14–24. http://dx.doi.org/10.1016/j.jsat.2006.12.031. Compton, W.M., Grant, B.F., Colliver, J.D., Glantz, M.D., & Stinson, F.S. (2004). Prevalence of marijuana use disorders in the United States: 1991–1992 and 2001–2002. JAMA, 291 (17), 2114–2121. Conger, J.J. (1956). Alcoholism: Theory, problem and challenge. II. Reinforcement theory and the dynamics of alcoholism. Quarterly Journal of Studies on Alcohol, 17, 296–305. Cooper, M.L. (1994). Motivations for alcohol use among adolescents: Development and validation of a four-factor model. Psychological Assessment, 6(2), 117–128. http://dx. doi.org/10.1037/1040-3590.6.2.117. Goldstein, R.Z., & Volkow, N.D. (2011). Dysfunction of the prefrontal cortex in addiction: Neuroimaging findings and clinical implications. Nature Reviews Neuroscience, 12 (11), 652–669. Johnson, K. A., Bonn-Miller, M. O., Leyro, T. M., & Zvolensky, M. J. (2009). Anxious arousal and anhedonic depression symptoms and the frequency of current marijuana use: Testing the mediating role of marijuana-use coping motives among active users. Journal Of Studies On Alcohol And Drugs, 70(4), 543–550. http://dx.doi.org/10.15288/ jsad.2009.70.543. Johnston, L.D., O'Malley, P.M., Bachman, J.G., Schulenberg, J.E., & Miech, R.A. (2014). Monitoring the future national survey results on drug use, 1975–2013: Volume 2, college students and adults ages 19–55. Ann Arbor: Institute for Social Research, The University of Michigan. Kaplan, H.B., Martin, S.S., Johnson, R.J., & Robbins, C.A. (1986). Escalation of marijuana use: Application of a general theory of deviant behavior. Journal of Health and Social Behavior, 44-61. Ketcherside, A., & Fi lbey, F.M. (2015). Mediating processes between stress and problematic marijuana use. Addictive Behaviors, 45, 113–118. http://dx.doi.org/10. 1016/j.addbeh.2015.01.015. Kraus, D.R., Seligman, D.A., & Jordan, J.R. (2005). Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: The treatment outcome package. Journal of Clinical Psychology, 61(3), 285–314. Larsen, R.J. (1984). Theory and measurement of affect intensity as an individual difference characteristic. Dissertation Abstracts International, 85, 2297B (UMI No. 8422112). Larsen, R.J., Diener, E., & Emmons, R.A. (1986). Affect intensity and reactions to daily life events. Journal of Personality and Social Psychology, 51(4), 803. 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, 576–600. Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Marsden, J., Gossop, M., Stewart, D., Rolfe, A., & Farrell, M. (2000). Psychiatric symptoms among clients seeking treatment for drug dependence intake data from the National Treatment Outcome Research Study. The British Journal of Psychiatry, 176(3), 285–289. Mischel, E.R., Leen-Feldner, E.W., Knapp, A.A., Bilsky, S.A., Ham, L., & Lewis, S. (2014). Indirect effects of smoking motives on adolescent anger dysregulation and smoking. Addictive Behaviors, 39(12), 1831–1838. http://dx.doi.org/10.1016/j.addbeh.2014.07.029. Nisbett, R.E., & Ross, L. (1980). Human inference: Strategies and shortcomings of social judgment. Englewood Cliffs, NJ: Prentice-Hall. Norberg, M.M., Olivier, J., Schmidt, N.B., & Zvolensky, M.J. (2014). Cannabis use among treatment-seeking smokers: Motives and the moderating effects of anxiety sensitivity. The American Journal on Addictions, 23(1), 7–14. http://dx.doi.org/10.1111/j.1521-0391. 2013.12054.x. Potter, C.M., Vujanovic, A.A., Marshall-Berenz, E.C., Bernstein, A., & Bonn-Miller, M.O. (2011). Posttraumatic stress and marijuana use coping motives: The mediating role of distress tolerance. Journal of Anxiety Disorders, 25(3), 437–443. http://dx.doi.org/ 10.1016/j.janxdis.2010.11.007. Rey, J.M., Sawyer, M.G., Raphael, B., Patton, G.C., & Lynskey, M. (2002). Mental health of teenagers who use cannabis results of an Australian survey. The British Journal of Psychiatry, 180(3), 216–221.

S. Semcho et al. / Addictive Behaviors 58 (2016) 85–89 Simons, J.S., & Gaher, R.M. (2005). The distress tolerance scale: Development and validation of a self-report measure. Motivation and Emotion, 29(2), 83–102. Simons, J., Correia, C.J., Carey, K.B., & Borsari, B.E. (1998). Validating a five-factor marijuana motives measure: Relations with use, problems, and alcohol motives. Journal of Counseling Psychology, 45(3), 265–273. http://dx.doi.org/10.1037/0022-0167.45.3. 265. Substance Abuse and Mental Health Services Administration (2014,). Results from the 2013 national survey on drug use and health: Summary of national findings. (NSDUH Series H-48, HHS Publication No. (SMA) 14-4863) Rockville, MD: Substance Abuse and Mental Health Services Administration. Van Dam, N.T., Bedi, G., & Earleywine, M. (2012). Characteristics of clinically anxious versus non-anxious regular, heavy marijuana users. Addictive Behaviors, 37(11), 1217–1223. http://dx.doi.org/10.1016/j.addbeh.2012.05.021.


Wolitzky-Taylor, K., Guillot, C.R., Pang, R.D., Kirkpatrick, M.G., Zvolensky, M.J., Buckner, J.D. , & Leventhal, A.M. (2015). Examination of anxiety sensitivity and distress tolerance as transdiagnostic mechanisms linking multiple anxiety pathologies to alcohol use problems in adolescents. Alcoholism: Clinical and Experimental Research, 39(3), 532–539. 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. http://dx.doi.org/10.1037/a0014961.