Journal of Contextual Behavioral Science 11 (2019) 1–5

Contents lists available at ScienceDirect

Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Psychological inflexibility as it relates to stress, worry, generalized anxiety, T

and somatization in an ethnically diverse sample of college students
Niloofar Tavakoli, Amanda Broyles, Erin K. Reid, J. Robert Sandoval,
⁎
Virmarie Correa-Fernández
Dept. of Psychological, Health, & Learning SciencesCollege of Education, University of Houston, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: Psychological inflexibility is conceptualized as rigid attempts to control psychological reactions to
Psychological inflexibility discomfort at the expense of values-guided actions. This construct has recently started to be examined in college
Psychological distress students, who experience considerable psychological distress. This study examined whether psychological in-
Anxiety flexibility was related to anxious symptomatology in an ethnically diverse sample of college students
College students
Method: Students (N = 538) completed a web-based survey that included questions regarding their psycholo-
Ethnicity
gical distress and well-being. Multiple regressions were used to examine the associations between psychological
inflexibility and stress, worry, generalized anxiety, and somatization while adjusting for age, sex, race/ethnicity,
and perception of socioeconomic status. The interaction between psychological inflexibility and race/ethnicity
in predicting outcomes was also examined
Results: The sample included individuals identifying as males (21.4%) and females (78.3%) between the ages of
18 and 74. The majority of participants were Hispanic-Americans (31.2%), followed by Asian-Americans
(30.0%), European-Americans (21.3%), African-Americans (13.2%), and "Other" (4.3%). There was a significant
association of psychological inflexibility on all four outcomes. High psychological inflexibility was positively
associated with the presence of stress, worry, generalized anxiety, and somatization, even after controlling for
demographic covariates. These associations were the same across race/ethnicities, except for the link between
psychological inflexibility and worry being lower for Hispanics-American compared to European- Americans
Conclusion: An individual's attempt to control and minimize experiencing unwanted feelings, thoughts, or events
is an important factor to consider in understanding college students’ anxious symptomatology. Teaching psy-
chological flexibility techniques through interventions such as acceptance and commitment therapy may help
students to better respond to psychologically distressing situations. Intervention research among diverse ethnic
groups is needed to further confirm and expand these findings.

During the last decade, clinical psychology literature has empha-
sized transdiagnostic approaches of understanding and improving
human functioning (Levin et al., 2014; Zvolensky & Leventhal, 2016).
Psychological inflexibility is one construct that has demonstrated evi-
dence of its utility as a transdiagnostic conceptualization of mental
health symptomatology (Hayes, Wilson, Gifford, Follette, & Strosahl,
1996; Levin et al., 2014). It refers to rigid attempts to control psycho-
logical reactions to discomfort (e.g., thoughts, affect), at the expense of
values-guided actions (Bond et al., 2011; Gamez, Chmielewski, Kotov,
Ruggero, & Watson, 2011; Levin et al., 2014). For instance, when dis-
tressing emotions and thoughts arise, individuals engaging in psycho-
logical inflexibility will tend to avoid, control or minimize their
experience and act in ways inconsistent with their values and what is
important to them. Psychological inflexibility is a key focus of Accep-
tance and Commitment Therapy (ACT), which conceptualizes this
construct as a contributor to psychopathology and general mental
health concerns (Fletcher & Hayes, 2005).
Control-focused propensities, such as emotional and thought sup-
pression, rumination, and experiential avoidance have been posed to
underlie many psychological disorders and predict an individual's
overall health and wellbeing (Aldao, Nolen-Hoeksema, & Schweizer,
2010; Tull, Gratz, Salters, & Roemer, 2004). For instance, higher levels
of psychological inflexibility have been associated with poor overall
psychological health (Bond et al., 2011; Masuda & Tully, 2012). Thus,

⁎
Correspondence to: Dept. of Psychological, Health, & Learning Sciences, College of Education, University of Houston, 491 Farish Hall, Houston, TX 77204-5029,
United States.
E-mail address: vcorreaf@central.uh.edu (V. Correa-Fernández).

https://doi.org/10.1016/j.jcbs.2018.11.001
Received 11 May 2018; Received in revised form 21 October 2018; Accepted 2 November 2018
2212-1447/ © 2018 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
N. Tavakoli et al.
examining psychological inflexibility may play a critical role in un-
derstanding and subsequently treating psychological distress in various
populations.
Kessler and colleagues (2005) found that mental health challenges
often have first onset during or shortly before the typical college age.
These students are particularly vulnerable to psychological distress,
perhaps because this transitional period is characterized by increased
independence, exploration of one's self, and new challenges (Arnett,
2000). Research has shown that, in a 12 month period, one third of
freshman students reported mental health problems, 57% of college
students felt overwhelming anxiety, and 15.8% received a diagnosis or
treatment for this condition (American College Health Association,
2015; Bruffaerts et al., 2018). Such distress can have a negative effect
on students’ academic functioning, adaptation to their environment,
and overall quality of life (American College Health Association, 2016;
Bruffaerts et al., 2018). Importantly, a study examining college students
found a large positive correlation between an individual's rigid psy-
chological reactions (psychological inflexibility) and experiencing
psychological distress (Masuda, Mandavia, & Tully, 2014). Thus, given
the high prevalence of anxiety among college students and the potential
contribution of psychological inflexibility to this type of distress, it is
important to examine how various presentations of anxiety are related
to psychological inflexibility in this population.
1. Psychological inflexibility and anxious symptomatology
A common presentation of anxious symptomatology is stress, which
has been defined as “the physiological or psychological response to
internal or external stressors” such as the uncertainty in one's ability to
meet life demands (Friedlander, Reid, Shupak & Cribbie, 2007;
VandenBos, 2015, p. 1036). Stressors are part of nearly everyone's daily
life; however, how one manages stress can impact nearly every system
in the body and can have an effect on one's affect and behaviors in-
cluding the amplification of negative emotions.
Some research has suggested psychological inflexibility as a con-
tributor to the development and maintenance of pathological worry,
another manifestation of anxious symptomatology (Hayes, Luoma,
Bond, Masuda, & Lillis, 2006; Ruiz, 2010, 2014a). Among university
students in Spain, it was found that individuals with more psychological
flexibility worried less (Ruiz, 2014b). Further, excessive worrying about
daily issues and difficulty controlling these worries are core compo-
nents of generalized anxiety disorder (GAD; National Institute of Mental
Health, 2016). According to a study conducted by Lee and Orsillo
(2014), individuals who reported higher levels of GAD also reported
more problems with cognitive inflexibility, which is conceptualized as a
subcomponent of psychological inflexibility (Whiting, Deane, Simpson,
McLeod, & Ciarrochi, 2017). However, although some research has
linked anxiety symptoms to psychological inflexibility (Masuda & Tully,
2012; Masuda et al., 2014), to the best of our knowledge, there is no
research explicitly examining the relationship between GAD and psy-
chological inflexibility in college students.
Individuals who attempt to control and minimize unwanted psy-
chological experiences may manifest their symptoms in physiological
ways and exhibit higher states of physiological arousal and somatiza-
tion (Gross & Levenson, 1997; Koh, Kim, Kim, Park, & Han, 2008).
Among college students, some research has documented that psycho-
logical flexibility was negatively associated with somatization (Masuda
& Tully, 2012; Masuda et al., 2014); and only one of these studies in-
cluded a diverse and large sample.
2. Present study
The present study aimed to replicate previously documented asso-
ciations between psychological inflexibility and somatization among
college students, and extend the relevant literature by examining re-
lationships between psychological inflexibility with acute stress, worry,
2
Journal of Contextual Behavioral Science 11 (2019) 1–5
and generalized anxiety in a more ethnically diverse sample.
Specifically, it was hypothesized that high psychological inflexibility
would be positively related to higher levels of stress, worry, generalized
anxiety, and somatization. Additionally, in an exploratory manner, we
examined if race/ethnicity moderated the association between psy-
chological inflexibility and the outcomes of interest.
3. Method
3.1. Participants
Data was obtained from an online study that examined associations
between psychosocial factors and health behavior practices among
college students. The sample included 538 university students in a
major metropolitan area in Texas. Study inclusion criteria included: 1)
Enrolled as a student at the university, 2) Have permission and avail-
ability to complete the survey for course credit, 3) Ability to use a
computer or handheld electronic device with internet access. No ex-
clusion criteria were identified beyond failure to meet the inclusion
criteria.
3.2. Procedure
Participants were recruited using the university's research man-
agement system. The study entailed the completion of a 50 min online
survey administered through the Qualtrics survey system. Participants
completed an electronic informed consent document at the beginning of
the survey and were granted course credit upon completion of the
survey.
3.3. Measures
3.3.1. Demographics
Participant demographics questionnaire included self-reported age,
sex (1 = male; 2 = female), race/ethnicity (1 = European-American,
2 = African-American, 3 =Asian-American, 4 =Hispanic-American,
5 =Other) and socioeconomic status (1 = living well or comfortable,
2 = living check to check to poor).
3.3.2. Acceptance and Action Questionnaire- II (AAQ-II)
The AAQ-II is a 7-item, unidimensional scale measuring psycholo-
gical inflexibility (Bond et al., 2011). Items are rated on a scale from 1
(never true) to 7 (always true), higher scores indicating greater levels of
psychological inflexibility (e.g., “My painful memories prevent me from
having a fulfilling life”). In our sample, the reliability coefficient of the
AAQ-II was α = 0.94.
3.3.3. Perceived Stress Scale (PSS)
The PSS is a four-item scale measuring the degree to which situa-
tions in life are considered stressful (Cohen, Kamarck, & Mermelstein,
1983). Each item is rated on a scale from 0 (never) to 4 (very often) on
how often in the last week the respondent has felt a certain way (e.g.,
“In the last week, how often have you felt that you were unable to
control the important things in your life?”). Two of the items are ne-
gatively worded, indicating less or no perceived stress. Total score is
calculated by summing the score for the positively worded items and
the reverse coded score of negatively worded items, with higher scores
indicating more perceived stress. In our sample, the reliability coeffi-
cient of the PSS was α = 0.65.
3.3.4. Penn State Worry Questionnaire (PSWQ)
The PSWQ is a 16-item scale measuring the trait of worry (Meyer,
Miller, Metzger, & Borkovec, 1990). Respondents rate each item on a
scale from 1 (not at all typical of me) to 5 (very typical of me). Eleven
items indicate problematic worry, with higher scores demonstrating
higher levels of worry (e.g., “My worries overwhelm me”). The other
N. Tavakoli et al. Journal of Contextual Behavioral Science 11 (2019) 1–5

five items are negatively worded, indicating worry is not a problem Table 1
(e.g., “I never worry about anything”). Total score is calculated by Frequencies for total sample and mean scores of psychological inflexibility for
summing positively worded items and the reverse scored negatively each subsample.
worded items. In our sample, the reliability coefficient of the PSWQ was Variable Total n (%) Mean (SD) of psychological
α = 87. inflexibility

Sex*
3.3.5. Generalized Anxiety Disorder Scale (GAD-7)
Female 421 (78.3) 21.28 (10.31)
The GAD-7 is a 7-item scale measuring symptoms of generalized Male 115 (21.4) 19. 27 (10.84)
anxiety disorder (GAD; Spitzer, Kroenke, Williams, & Lowe, 2006). Age**
Respondents are instructed to rate how often specific problems related 18–25 484 (90.3) 21.1 (10.33)
26–74 52 (9.7) 17.75 (10.57)
to anxiety have bothered them over the last 2 weeks on a scale from 0
Race/Ethnicity*
(not at all) to 3 (nearly every day) and total score is calculated but European-American 114 (21.3) 20.13 (10.98)
summing the score of each item. Total scores of less than four represent African-American 71 (13.2) 20.90 (8.95)
minimal levels of symptom burden, five to nine represents mild, 10–14 Asian-American 161 (30.0) 22.43 (10.51)
moderate, and scores of 15 or greater represent severe. In our sample, Hispanic-Americans 167 (31.2) 19.44 (10.55)
Other 23 (4.3) 23.55 (9.47)
the reliability coefficient of the GAD-7 was α = 0.93.
SES Perception**
Living well/comfortably 372 (69.4) 19.98 (10.10)
3.3.6. Patient Health Questionnaire- Somatic Symptom Scale (PHQ-15) Living from check to check/ 164 (30.6) 22.83 (10.96)
The PQH-15 is a 15-item scale that assesses respondent's ratings of almost poor/ poor
how much somatic symptoms have bothered them within the last 2
Note. SES = socioeconomic status.
weeks (Spitzer, Kroenke, & Williams, 1999). The items are rated on a
* p < .10.
scale from X (not at all) to 3 (nearly every day), and total score is cal-
** p < .05. Two cases had missing data.
culated buy summing the score of each item. Total scores of 0–4 re-
present minimal levels of symptom burden, 5–9 represents mild, 10–14
Table 2
moderate, and scores of 15 or greater represent severe. In our sample, Associations between psychological inflexibility and each outcome.
the reliability coefficient of the PHQ-15 was α = 0.85.
Outcome variable B value S.E. BETA Z value

3.4. Data analysis Stress 0.062 0.011 0.252 5.891

Worry 0.665 0.049 0.498 13.479
Descriptive statistics were conducted to summarize participants’ Generalized Anxiety 0.334 0.019 0.6 17.332
characteristics. Separate multiple regression models were performed to Somatization 0.191 0.019 0.397 10.256

examine the associations between psychological inflexibility and the

outcomes of interest (i.e., stress, worry, generalized anxiety, and so-
matization), while also adjusting for age, sex, race/ethnicity, and SES.
These sociocultural determinants were selected as covariates because
they are known predictors of the presentations of distress examined in
this study (i.e., sex and SES) or they may differentially relate to psy-
chological inflexibility (age and race/ethnicity). Additionally, to ex-
amine if race/ethnicity moderated the relationship between psycholo-
gical inflexibility and the outcomes of interest, interaction terms were
created between psychological inflexibility and each of the race/eth-
nicity subgroups. Analyses were conducted using Mplus. Missing data
(maximum missing for a variable was 2%) was handled by using the
maximum likelihood estimator in Mplus (Mplus default for continuous
dependent variables) assuming missing at random (MAR; Enders,
2010).
4. Results
Note: Analyses are adjusted for age, sex, race/ethnicity, and perception of so-
cioeconomic status; all ps < .001.
(AAQII) was significantly associated with increases of 0.062, 0.665,
0.334, and 0.191 in PSS, PSWQ, GAD-7 and PHQ-15, respectively,
while holding the other variables in the model constant (all ps <
0.001; Table 2). In regards to the ethnicity moderation, only one of the
models was statistically significant. The interaction between psycho-
logical inflexibility and being Hispanic-American (vs. European-Amer-
ican) was significantly related with worry. Specifically, compared to the
reference group, Hispanics-American had significantly lower associa-
tion between psychological inflexibility (AAQII_Total) and worry scores
(PSWQ_Total), B = -0.295 (S.E. = 0.13); BETA = -0.228, z = -2.267;
p = .023. There was no significant interaction between psychological
inflexibility and race/ethnicity in the prediction of PSS, GAD-7 or PHQ-
15 scores.

The sample was racial/ethnically diverse, with the majority self-
identifying as Hispanic-Americans (31.2%), followed by Asian-
Americans (30.0%), European-Americans (21.3%), African-Americans
(13.3%) and Other (4.3%). The mean age of the sample was 21.66
(SD = 4.8). The majority of participants were female (78.5%). Table 1
shows the descriptives of the total sample as well as the mean scores
and standard deviations of psychological inflexibility. Bivariate ana-
lyses indicated that demographic variables were significantly related to
psychological inflexibility.
Preliminary assumptions testing was conducted to check for nor-
mality, linearity, outliers, multicollinearity, and homogeneity of var-
iance-covariance matrices, with no serious violations noted. Findings
from the regression analyses indicated that higher psychological in-
flexibility was positively related with higher levels of stress, worry,
generalized anxiety, and somatization, even after controlling for de-
mographic covariates (i.e. age, sex, race/ethnicity, and SES). On
average, a one-unit increase in psychological inflexibility scores
5. Discussion
The present study investigated the relationships between psycho-
logical inflexibility and stress, worry, generalized anxiety and somati-
zation in a large and ethnically diverse sample of urban college stu-
dents, including European-Americans, African-Americans, Asian-
Americans and Hispanic-Americans. Psychological inflexibility, as
measured by the AA-II, was positively associated with the aforemen-
tioned manifestations of anxious symptomatology, consistent with hy-
potheses. This is, students who reported higher levels of psychological
inflexibility also experienced higher levels of anxious symptomatology
when compared to students who reported lower levels of psychological
inflexibility. Notably, moderation analyses demonstrated that the po-
sitive relationship between psychological inflexibility and worry was
stronger for European- Americans compared to Hispanic-Americans.
For other outcomes, no differences by race/ethnicity emerged.
The positive relationship between psychological inflexibility and

3
N. Tavakoli et al.
higher levels of various presentations of anxious symptomatology in our
sample are consistent with previous findings linking psychological in-
flexibility to somatization in college samples (Masuda & Tully, 2012;
Masuda et al., 2014), and are in line with findings from Ruiz (2014b)
which found that Spaniard university students who exhibited more
psychological flexibility tended to worry less. Along the same line, this
study expands previous relevant research (Lee & Orsillo, 2014; Roemer,
Salters, Raffa, & Orsillo, 2005; Tull et al., 2004) and document that
greater psychological inflexibility is associated with greater self-re-
ported acute stress and generalized anxiety in this population. Findings
suggest that individuals who display rigidity in their beliefs and me-
tacognitions may be unable to detach from their symptoms and may fail
to utilize adaptive coping strategies to effectively cope with anxiety
(Wells, 2009). Of note, with the exception of worry, all the constructs
examined in this study were significantly related to psychological in-
flexibility in a similar way across race/ethnicities. There was a lower
association between psychological inflexibility and worry in Hispanic-
Americans compared to European-Americans suggesting that additional
factors may influence worry levels among this subpopulation. This
finding also highlight the importance of considering sociocultural fac-
tors when examining relationships between transdiagnostic constructs
and psychological distress.
The results of the present study underscore the importance of con-
sidering an individual's attempt to control experiencing unwanted
feelings, thoughts, or events as a vital factor in understanding college
students’ stress, worry, generalized anxiety, and somatic symptoms.
Strengthening psychological flexibility can help reduce stress via re-
duction in tendencies towards avoiding unwanted emotional experience
(Brinkborg, Michanek, Hesser, & Berglund, 2011; Dahl, Wilson, &
Nilsson, 2004; Flaxman & Bond, 2010). Thus, teaching psychological
flexibility techniques through interventions such as ACT may help in-
dividuals to increase their willingness and ability to experience psy-
chological distress in their daily lives as previously supported by other
authors (Hayes et al., 2006; Ruiz, 2014a). Furthermore, if types of
anxious symptomatology differentially relate to psychological inflex-
ibility across some ethnic groups, this suggests a potential need to
culturally-adapt interventions focused on increasing psychological
flexibility in order to address anxiety symptoms.
6. Limitations
The present study had several limitations. First, the study relied
exclusively on self-report; therefore, clinical diagnosis was not assessed,
the participant responses may be prone to social desirability, and re-
porting bias cannot be ruled out. However, a self-report methodology
facilitated the screening of a large sample of students. Second, the study
utilized a cross-sectional design; therefore, no inferences about caus-
ality among variables can be made and results may not be generalizable
to the adult population in the US. Finally, the current study utilized a
college sample which may not be representative of the adult population
of the US. Consequently, more research is needed employing more
rigorous methodologies and study designs as well as intervention stu-
dies to confirm these findings.
7. Strengths and future research
Despite these limitations, the study had several strengths. It ex-
amined the transdiagnostic construct of psychological inflexibility
linked to various manifestations of anxious symptomatology, not all of
which have been examined in a college sample. A particular contribu-
tion of the study is the utilization of a larger and more ethnically di-
verse sample (i.e., African-Americans and Hispanic-Americans) com-
pared to similar studies reported in the literature. Notably, our sample
includes 31% of Hispanics, a population among which these relation-
ships have rarely been examined.
4
Journal of Contextual Behavioral Science 11 (2019) 1–5
8. Conclusion
Our findings show a positive association between psychological
inflexibility and various manifestations of anxious symptomatology in
an ethnically diverse sample of college students, which suggests the
potential applicability of these findings into other ethnically diverse
samples. It is essential that future work examine longitudinal associa-
tions among variables, as well as psychosocial moderators of the asso-
ciations between psychological inflexibility as it relates to stress, worry,
generalized anxiety, and somatization in college students in an effort to
increase our understanding of these relationships. Importantly, inter-
vention research should test the effect of increasing psychological
flexibility (as opposed to psychological inflexibility) in reducing stu-
dents’ anxious symptomatology and, in turn, improve their overall
wellbeing.
Acknowledgements
Authors would like to acknowledge the assistance of Josée K.
Kahambwe and Lena M. Musoka in conducting literature reviews and
editing the references for this paper. Authors are also thankful for the
consultanship of Dr. Hanjoe Kim while managing missing data and
analyzing the data in Mplus.
This work was partially supported by an award from the American
Cancer Society (MRSG-15–018-01-CPPB, to Virmarie Correa-
Fernández). The content of this paper is solely the responsibility of the
authors and do not necessarily represent the official views of the sup-
porting organization.
Conflicts of interest
Authors declare no conflict of interest.
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