Distress Tolerance and Self-Injurious Thoughts and Behaviors: A systematic review and commentary on methodological challenges.

Impaired distress tolerance (DT) is theorized to be an etiological and maintenance factor for self-injurious thoughts and behaviors (SITBs). However, the literature on DT and SITBs suffers from conflicting results and methodological challenges, and thus, is difficult to interpret.

Objectives: We conducted a systematic review to synthesize available evidence on DT and the full range of SITBs.

Methods: We included peer-reviewed, English-language manuscripts presenting empirical data on DT/intolerance in relation to SITB among humans. Studies were identified via a search covering results published through December 31, 2024 at Academic Search Premier, MEDLINE, PsychINFO, and PubMed (most recently executed June 20th, 2025). No formal risk of bias assessments were used. Results were synthesized by DT assessment type (self-report, behavioral, combined) and study approach (observational, longitudinal, intervention). Of the 1058 studies screened, 81 were eligible for inclusion with 30,052 participants. This review was neither funded nor preregistered.

Results: Self-report measures appear to assess distress intolerance rather than high tolerance/endurance abilities. Findings generally indicate lower scores reflecting greater intolerance are associated with SITB across both suicide-related and non-suicidal self-injury outcomes; however, there are notable exceptions, and significant limitations associated with sample selection and research design that makes interpretation challenging.

Discussion: The vast majority of results were obtained with a single self-report measure at one point in time. Laboratory paradigms reviewed seem to have poor ecological validity with limited relevance to the contexts in which SITBs emerge, and produced mixed associations with SITB. Within-person variability in DT has largely gone unexamined, and important mediators and moderators are underexplored. We discuss several areas for further research.