Heightened adolescent emotional reactivity in the brain is associated with lower future distress tolerance and higher depressive symptoms

Estimates indicate that half of the United States population will endure a mental health diagnosis, with adolescence being a time of increased onset (Kessler et al., 2005; Merikangas et al., 2010; Twenge et al., 2019). Further, experiencing behavioral or emotional problems at an earlier age puts youth at greater risk for later impairment due to mental health concerns as adults (Hofstra et al., 2002). Therefore, studying neurobiological and psychological risk and resiliency factors related to psychopathology during this developmental period is important for early prevention and treatment efforts.

Distress tolerance, conceptualized as an individual's ability to withstand and continue engagement in goal-directed behaviors while also experiencing negative or distressing psychological states, may serve as an important transdiagnostic marker of mental health (Zvolensky et al., 2010). Previous literature has demonstrated the potential role of distress tolerance as a risk/resiliency factor in a number of psychopathologies, including alcohol and substance use (Buckner et al., 2007; Webb et al., 2020), post-traumatic stress disorder (Simons et al., 2021), disordered eating behaviors (Kelly et al., 2014), non-suicidal self-injury and suicidal ideation (Anestis et al., 2013; Lin et al., 2018), early engagement in substance use (Kechter et al., 2021), obsession- and anxiety-related behaviors (Laposa et al., 2015; Qi et al., 2021), and depression (Felton et al., 2019; Felton et al., 2020). Similarly, the impact of negative life events on future depressive symptoms has been shown to be moderated by distress tolerance in adolescents (Felton et al., 2019). Clinical interventions aimed at strengthening distress tolerance skills (McHugh et al., 2014; Williams et al., 2013) have proven effective with increased tolerance for distress associated with fewer internalizing symptoms (Williams et al., 2013). As such, understanding individual differences in neurobiology and psychological features of distress tolerance may be important for identifying those at risk for future onset and progression of psychopathology.

Emotional reactivity, or an individual's response in emotional intensity and arousal, may act as a potential contributing factor to overall abilities to tolerate distress. Greater levels of self-reported general emotional reactivity and reactivity while viewing emotionally charged information are associated with lower distress tolerance (Bruns et al., 2019; Cougle et al., 2013). Additionally, self-reported emotional reactivity has been shown to partially explain the relationship between psychopathology and maladaptive coping strategies, such as self-injurious behaviors (Nock et al., 2008). Importantly, distress tolerance has been shown to temporally mediate the association between self-reported emotional reactivity and suicidal ideation (Wu et al., 2021), suggesting that heightened emotionality may precede impaired distress tolerance and serve as an early predictor of future internalizing symptoms. However, previous emotional reactivity measures heavily relied on self-report measures, and have limited our understanding of potential neurobiological underpinnings of these emotional processes and reactivity. The current study aimed to build upon this work by investigating the associations between the neurobiological correlates of processing emotional stimuli and future distress tolerance, as well as depressive symptoms in adolescents.

Adolescence is a time of heightened sensitivity to emotion and reward (Crone et al., 2016; Galván, 2010) and acts as a period of ongoing plasticity for associated neurocircuitry (Casey et al., 2008). To date, functional magnetic resonance imaging (fMRI) studies have largely investigated associations between distress tolerance and brain connectivity in adults. For example, greater resting-state connectivity between the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (dlPFC), greater connectivity between the default mode and salience networks, and greater connectivity within the executive control network, was associated with greater distress tolerance (Dezachyo et al., 2021; Reese et al., 2019). Similarly, greater activation during a distress tolerance task in cognitive control and limbic areas (i.e., insula, ACC, and medial/inferior/ventromedial prefrontal cortex) was associated with higher distress tolerance in adults using substances (Daughters et al., 2017). These results highlight the role of the cognitive control and salience networks (and interaction with other networks) in distress tolerance and maladaptive coping behaviors; however, no studies have investigated the relationship between neurobiological response to emotionally-valenced stimuli and distress tolerance.

The present study aimed to investigate: 1) the association between neural correlates of emotional reactivity in adolescents and future distress tolerance, and 2) how the relationship between emotional reactivity and distress tolerance relates to symptoms of depression. With this in mind, whole-brain voxel-wise analysis was utilized to identify regions of the brain active during emotional processing that were significantly associated with self-reported distress tolerance at a two-year follow-up. Based on prior literature, we hypothesized that greater activation in areas involved in cognitive control, such as the dlPFC and ACC, would be associated with greater distress tolerance. Then, post-hoc analyses were carried out to test distress tolerance as a potential mediator between brain response during emotional processing and depressive symptoms at two-year follow-up. We hypothesized that distress tolerance would play a mediating role between emotional reactivity brain response and depressive symptoms, as has been similarly demonstrated behaviorally (Wu et al., 2021).

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