Distress Tolerance Scale

The Distress Tolerance Scale (DTS) is a validated 15-item instrument that evaluates a patient's perceived ability to withstand negative emotional states.

Questions: 15
Duration: 5 min
Original title: DTS — Distress Tolerance Scale
Adaptation: Distress Tolerance Scale
Authors: Simons, J. S. & Gaher, R. M.
Created: 2005

The Distress Tolerance Scale (DTS) is a validated 15-item instrument that evaluates a patient's perceived ability to withstand negative emotional states. Rather than measuring the frequency or intensity of distress, the DTS focuses entirely on the patient's relationship to their own negative emotions, specifically whether they believe emotional discomfort is bearable, acceptable, or inherently dangerous. Developed by Simons and Gaher (2005), it provides clinicians with a robust metric for assessing emotion-regulation vulnerabilities across a wide range of psychological presentations.

In clinical practice, low distress tolerance is a recognized transdiagnostic risk factor often driving impulsive behaviors, experiential avoidance, and maladaptive coping. By quantifying how patients experience, evaluate, and respond to emotional pain, the DTS helps clinicians track changes in distress tolerance over the course of therapy. It serves as an excellent baseline measure when planning acceptance-based interventions like urge surfing, allowing practitioners to monitor whether therapeutic efforts translate into a genuinely increased capacity to sit with emotional discomfort.

Example result

Fictitious result, computed from a sample set of answers.

Overall score

3.125/ 5

The DTS is a 15-item self-report questionnaire assessing perceived emotional distress tolerance, defined as an individual's perceived capacity to experience and withstand negative emotional states. It assesses four dimensions: tolerance (perceived ability to withstand distress), absorption (the extent to which attention is consumed by negative emotions), appraisal (subjective evaluation and acceptability of distress), and regulation (efforts implemented to reduce distress). Used in clinical and research settings, it represents a relevant transdiagnostic marker for anxiety disorders, addictive behaviors, and emotion regulation difficulties.

généralemixed · students · 19–63 years · Spain · n = 650 · 2017 · Sandín et al. (2017)

3.125

M = 3.48 ± 0.84

généralemen · students · men · Spain · n = 187 · 2017 · Sandín et al. (2017)

3.125

M = 3.65 ± 0.81

généralewomen · students · women · Spain · n = 463 · 2017 · Sandín et al. (2017)

3.125

M = 3.41 ± 0.84

généralemixed · students · no history of self-harm · 17–25 years · Australia · n = 316 · 2021 · Slabbert et al. (2021)

3.125

M = 3.22 ± 0.79

cliniquemixed · pathology: Non-suicidal self-injury · with a history of self-harm · 17–25 years · Australia · n = 215 · 2021 · Slabbert et al. (2021)

3.125

M = 2.52 ± 0.77

Scoring

Mean of subscale means (overall score); mean per subscale, total score from 1 to 5, each item is scored on a 5-point scale (from 1 to 5).

Appraisal

2.5/ 5

Appraisal of one's own distress, perceived as acceptable or shameful.

items 6, 7, 9, 10, 11, 12

généralemixed · students · 19–63 years · Spain · n = 650 · 2017 · Sandín et al. (2017)

2.5

M = 3.84 ± 0.88

généralemixed · students · no history of self-harm · 17–25 years · Australia · n = 316 · 2021 · Slabbert et al. (2021)

2.5

M = 3.42 ± 0.84

cliniquemixed · pathology: Non-suicidal self-injury · with a history of self-harm · 17–25 years · Australia · n = 215 · 2021 · Slabbert et al. (2021)

2.5

M = 2.59 ± 0.87

Tolerance

3/ 5

Perceived capacity to withstand emotional distress.

items 1, 3, 5

généralemixed · students · 19–63 years · Spain · n = 650 · 2017 · Sandín et al. (2017)

M = 3.31 ± 1.1

généralemixed · students · no history of self-harm · 17–25 years · Australia · n = 316 · 2021 · Slabbert et al. (2021)

M = 3.22 ± 1.01

cliniquemixed · pathology: Non-suicidal self-injury · with a history of self-harm · 17–25 years · Australia · n = 215 · 2021 · Slabbert et al. (2021)

M = 2.53 ± 1.01

Absorption

3.667/ 5

Degree to which attention is absorbed by negative emotions.

items 2, 4, 15

généralemixed · students · 19–63 years · Spain · n = 650 · 2017 · Sandín et al. (2017)

3.667

M = 3.33 ± 1.17

généralemixed · students · no history of self-harm · 17–25 years · Australia · n = 316 · 2021 · Slabbert et al. (2021)

3.667

M = 3.18 ± 1.01

cliniquemixed · pathology: Non-suicidal self-injury · with a history of self-harm · 17–25 years · Australia · n = 215 · 2021 · Slabbert et al. (2021)

3.667

M = 2.25 ± 0.98

Regulation

3.333/ 5

Efforts made to quickly alleviate distress.

items 8, 13, 14

généralemixed · students · 19–63 years · Spain · n = 650 · 2017 · Sandín et al. (2017)

3.333

M = 3.08 ± 1.12

généralemixed · students · no history of self-harm · 17–25 years · Australia · n = 316 · 2021 · Slabbert et al. (2021)

3.333

M = 3.03 ± 0.89

cliniquemixed · pathology: Non-suicidal self-injury · with a history of self-harm · 17–25 years · Australia · n = 215 · 2021 · Slabbert et al. (2021)

3.333

M = 2.7 ± 0.94

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What the test measures

The DTS measures the multidimensional construct of distress tolerance, breaking down the patient's relationship to negative affect into four distinct clinical facets. It focuses on subjective beliefs about emotional pain rather than objective distress levels.

Tolerance: The core perceived ability to endure emotional distress without feeling completely overwhelmed or destroyed.
Absorption: The degree to which the patient's attention becomes hijacked and consumed by the negative emotion.
Appraisal: The subjective evaluation of the distress itself, tracking whether uncomfortable feelings are judged as unacceptable or shameful.
Regulation: The compulsive behavioral drive to escape, avoid, or immediately alleviate the negative state, often leading to maladaptive coping.

The DTS is validated for adult populations and is particularly useful for patients presenting with emotion-regulation difficulties, anxiety disorders, substance use, or impulsive behaviors.

When and why to use it

The DTS is a highly versatile instrument used to identify distress intolerance as a driving mechanism behind various clinical presentations. It helps clarify whether a patient's primary difficulty is the presence of negative emotion or their rigid refusal to experience it.

Intake baseline: To assess the patient's capacity to tolerate affective pain before introducing concrete distress tolerance skills or beginning trauma processing.
Monitoring therapeutic progress: To measure shifts in emotional resilience throughout an intervention, particularly in dialectical behavior therapy or acceptance and commitment therapy.
Differential support: To distinguish between patients who lack emotion regulation strategies and those who abandon them because they cannot tolerate uncertainty or temporary distress.
Evaluating avoidance behaviors: To map how catastrophic appraisals of distress fuel the immediate urge to escape, often perpetuating the clinical problem.

Using a validated measure like the DTS provides a structured, quantitative baseline that complements clinical observation, making the abstract concept of distress tolerance visible and measurable.

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The questions

Think of times that you feel distressed or upset. Select the option that best describes your beliefs about feeling distressed or upset.
1. Feeling distressed or upset is unbearable to me.
Probes the patient's core belief about their absolute capacity to withstand emotional pain.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
2. When I feel distressed or upset, the only thing I can think about is how intense my distress is.
Assesses how completely negative emotions capture and dominate the patient's attentional focus.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
3. I can't stand feeling distressed or upset.
Evaluates the perceived inability to manage or survive emotional discomfort.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
4. My feeling of distress is so intense that it completely overwhelms me.
Measures the subjective experience of being entirely engulfed by emotional distress.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
5. There's nothing worse than feeling distressed or upset.
Explores whether the patient catastrophizes the experience of emotional discomfort.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
6. I can tolerate being distressed or upset as well as most people.
Frames the patient's distress tolerance comparatively, assessing self-efficacy relative to others.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
7. My feelings of distress or upset are not acceptable.
Evaluates the rigid invalidation or rejection of one's own negative affective states.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
8. I would do anything to avoid feeling distressed or upset.
Explores the behavioral lengths the patient will go to in order to preempt emotional pain.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
9. Other people seem more able to tolerate feelings of distress or upset than I am.
Examines feelings of inadequacy or isolation regarding emotional resilience.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
10. Being distressed or upset is always a major ordeal for me.
Assesses whether the patient views typical emotional fluctuations as catastrophic events.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
11. I feel ashamed of myself when I feel distressed or upset.
Probes secondary emotions, specifically shame associated with experiencing psychological distress.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
12. I am afraid of my feelings of distress or upset.
Evaluates the presence of affective fear, where the emotion itself becomes a source of anxiety.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
13. I would do anything to stop feeling distressed or upset.
Measures the desperation and urgency to terminate negative emotional experiences once they begin.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
14. When I feel distressed or upset, I have to do something about it immediately.
Assesses the impulsive, urgent drive for immediate symptom relief.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree
15. When I feel distressed or upset, I can't help but focus on how intense my distress is.
Tracks rumination and the inability to redirect attention away from the distress.
- Strongly agree
- Somewhat agree
- Neither agree nor disagree
- Somewhat disagree
- Strongly disagree