ALPIMS • UNDERSTANDING OVERLAP
Bodily Symptoms, Anxiety & Trauma Overlap
Explore conditions through the six ALPIMS domains, compare overlapping patterns and find support that fits.
Similar symptoms can have different causes
Medical conditions, neurodevelopmental differences and PTSD/complex PTSD can coexist. These comparisons are clues for assessment—not a way to diagnose yourself or rule out trauma.
One diagnosis should not automatically explain every symptom.
Normal routine tests do not exclude every medical condition. Feeling frightened does not prove a psychological cause; not recognising a trauma reminder does not rule out PTSD.
Where DBT may help
Dialectical Behaviour Therapy (DBT) teaches skills for attention, intense emotions, difficult moments and communication.
You can have real physical symptoms and benefit from coping support. A skill helping does not prove that anxiety or trauma caused the symptoms.
These suggestions are practical adaptations, not evidence that DBT treats every condition listed. Medical care, sensory accommodations and pacing still matter.
Start small: choose one concern, then one skill. A supporter can read or practise with you.
Explore conditions by ALPIMS domain
These are practical starting points, not a medical classification or a complete list of conditions. A condition can involve several domains.
Placement does not establish cause. Autonomic symptoms are not automatically anxiety; sensory differences are not automatically trauma; FND is not automatically a mental health condition.
Open one domain, then one condition. Select a recommended skill to open its short explanation.
A — Anxiety & Autonomic
This domain brings together anxiety experiences and autonomic symptoms for exploration. POTS is an autonomic condition; it is not an anxiety disorder.
POTS / orthostatic intolerance
What can overlap?
Racing heart, shaking, dizziness and brain fog.
What may differ?
Symptoms repeatedly worsen upright and may ease lying down. Assessment looks for a characteristic heart-rate/blood-pressure pattern. PTSD does not require this positional pattern.
What may help?
Ask about orthostatic assessment. Sit or lie down when symptomatic. Discuss fluids, salt or compression with your clinician; suitability varies.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Pause, notice symptoms and choose the safest next step. This may reduce panic-driven decisions while you follow your POTS plan.
One small example: “I feel frightened and dizzy. I can lie down and ask for help.”
Adapt to your needs: Practise sitting or lying down. Do not use intense exercise, breath-holding or cold-water face immersion as a default calming tool.
L — Laxity / Connective Tissue
Explore joint hypermobility, instability and related support needs. Pain and autonomic concerns may need their own assessment.
Hypermobility spectrum disorders (HSD) / hypermobile EDS
What can overlap?
Pain, fatigue, dizziness and anxiety can occur alongside symptomatic hypermobility and may resemble parts of a trauma response.
What may differ?
Joint hypermobility, instability and recurrent injuries need assessment in their own right. HSD and hypermobile Ehlers–Danlos syndrome (hEDS) have different diagnostic criteria. Being flexible alone does not establish either diagnosis.
What may help?
Seek assessment and an individual plan for joint protection, appropriate rehabilitation and pain. Assess accompanying symptoms separately, including orthostatic intolerance where relevant.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Plan around physical limits, prepare for demanding situations and request seating, breaks or practical assistance.
One small example: “My joints need support. I can ask for a chair and split this task.”
Adapt to your needs: Avoid painful stretching or muscle tensing as calming exercises. Skills support coping; they do not correct connective-tissue differences. Respect PEM if present.
P — Pain / Bodily Sensitivity
Explore pain and bodily discomfort. Migraine also involves sensory processing; gut and pelvic symptoms can have several contributing mechanisms.
Migraine
What can overlap?
Sensory sensitivity, irritability, withdrawal and brain fog.
What may differ?
Episodes may include headache, nausea, light/sound sensitivity or aura. These can occur without trauma reminders.
Migraine aura and persistent visual snow are different phenomena.
What may help?
Reduce glare and noise during attacks. Seek a migraine treatment plan and support a tolerable sleep and meal routine.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: PLEASE encourages care of physical illness, regular nourishment and sleep. Gentle self-soothing may ease emotional distress during an attack.
One small example: “I can take my prescribed treatment and rest somewhere dim and quiet.”
Adapt to your needs: Choose tolerable input, not extra stimulation. Avoid strong smells, ice or sound if these worsen symptoms; adapt movement to capacity and PEM.
Fibromyalgia / chronic pain
What can overlap?
Pain, tension, poor sleep, fatigue and reduced activity.
What may differ?
Persistent pain patterns need assessment in their own right. Pain alone does not establish PTSD; trauma may contribute in some people.
What may help?
Seek a personalised pain plan and adapt activity to capacity. Check for PEM before recommending activity increases. Treat sleep and coexisting conditions.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Acceptance may ease the struggle with today’s limits. Physical care and a small accessible pleasure can support wellbeing alongside pain treatment.
One small example: “This hurts. I can ask for care and choose one comforting thing.”
Adapt to your needs: Acceptance does not mean liking pain, giving up treatment or tolerating harm. Avoid prolonged body scans or muscle tensing if these worsen pain; respect PEM.
IBS / bladder or pelvic pain
What can overlap?
Gut discomfort, urgency, tension and distress.
What may differ?
Symptoms may track bowel movements, bladder filling or other bodily patterns. Stress sensitivity does not establish a trauma cause.
What may help?
Seek condition-specific assessment. Keep changes manageable and avoid broad dietary restriction without guidance. Pelvic-floor care may help when clinically indicated.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Plan toilet access, breaks and a clear request for privacy. A tolerable comfort may reduce the distress that accompanies symptoms.
One small example: “I need access to a toilet and may need to leave briefly.”
Adapt to your needs: Do not delay toileting or dismiss new symptoms to practise distress tolerance. Avoid unfamiliar foods, pressure, heat or muscle tensing that aggravates symptoms.
I — Immune / Inflammatory
Explore allergic and mast-cell concerns. Similar symptoms do not establish a shared immune cause.
MCAS / allergic-type episodes
What can overlap?
Palpitations, breathlessness, dizziness and feeling physically alarmed.
What may differ?
Hives, itching, flushing, swelling or diarrhoea alongside episodes suggest assessment for mast-cell activation.
Symptoms alone do not confirm MCAS; clinical and laboratory criteria matter.
What may help?
Follow your clinician’s treatment and emergency plan. Note suspected triggers without deliberately testing them. Avoid unnecessary food restrictions.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Pause and follow your medical plan rather than spending time deciding whether symptoms are anxiety. Rehearse who to contact and where medicines are kept.
One small example: “First I follow my agreed treatment plan. Coping skills can come afterwards.”
Adapt to your needs: Self-soothing must avoid your triggers: scents, heat, cold or particular foods may be unsuitable. Skills do not treat anaphylaxis or replace emergency care.
M — Mood / Mental Health
Explore trauma-related mental health concerns here. PTSD and complex PTSD are not simply mood disorders, and physical illness can coexist.
PTSD / complex PTSD
What can overlap?
Can include many of the symptoms described in the other sections.
What may differ?
Trauma-related re-experiencing and avoidance are distinguishing features. Complex PTSD also includes persistent difficulties with emotion regulation, self-concept and relationships.
Symptoms need not have an obvious reminder every time.
What may help?
Seek trauma-informed assessment and appropriately adapted treatment. Offer choice, consent and predictable sessions, while respecting physical and sensory limits.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Pause before acting on a strong urge, acknowledge that your feelings make sense and choose a safe response. Clear requests and boundaries may support relationships.
One small example: “This feels threatening. I can check my present safety and ask for space.”
Adapt to your needs: Start with consent and an eyes-open external anchor if that feels safer. Stop inward-focused exercises if they increase dissociation. DBT skills can complement appropriate trauma-focused treatment; they do not require accepting abuse.
S — Sensory / Neurodevelopmental
Explore sensory experiences and neurodevelopmental differences. Visual snow is a neurological syndrome; placing it here reflects its sensory features.
Autism / ADHD
What can overlap?
Concentration difficulties, emotional dysregulation, overwhelm and withdrawal.
What may differ?
Assessment considers developmental history and longstanding patterns across settings. Trauma can add or intensify difficulties. A late diagnosis does not mean late onset.
What may help?
Offer clear choices, predictable plans, manageable tasks and sensory adaptations. Support trauma-related difficulties separately where present.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Do one manageable thing at a time, recognise a small achievable success and request clear instructions or accommodations.
One small example: “Please give me one written step. I can do the next step later.”
Adapt to your needs: Use literal language, visual prompts and extra processing time. Mindfulness need not mean stillness or eye contact. Avoid making skills a demand to mask or suppress harmless self-regulation.
Misophonia
What can overlap?
Intense distress, anger, disgust, bodily arousal and an urge to escape.
What may differ?
Reactions centre on particular sound patterns or their meaning/context, such as chewing or repetitive tapping—not necessarily loudness. A traumatic memory is not required.
With PTSD, a sound may act as a trauma reminder. Both can coexist.
What may help?
Agree a brief exit signal, quieter seating or tolerable background sound. Use hearing protection selectively when helpful.
A clinician familiar with misophonia may offer adapted CBT; evidence is developing. Do not impose exposure or deliberate trigger sounds.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Pause before responding in anger, ask clearly for a practical accommodation and plan a brief exit. This may protect relationships during intense reactions.
One small example: “That sound is overwhelming. Please let me move seats; I will return when able.”
Adapt to your needs: Reduce the trigger first. Skills are not a requirement to endure sounds or a replacement for accommodations. Rehearse when calm, not during peak distress.
Hyperacusis / sensory overload
What can overlap?
Startle, distress, escape, overwhelm or shutdown.
What may differ?
Hyperacusis concerns reduced tolerance of sound intensity; misophonia concerns specific triggers. Sensory overload can follow accumulated input or demands.
Trauma-related sound distress may involve reminders of danger; the patterns can overlap.
What may help?
Seek audiology assessment for sound intolerance. Adapt noise, light and demands.
Discuss hearing protection with an audiologist; avoid assuming constant protection or forced exposure is the right approach.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Pause demands, reduce input and communicate a need for quiet. A personally tolerable comfort may help you recover from overwhelm.
One small example: “I need quiet and fewer questions. Please give me some space.”
Adapt to your needs: Do not add music, scents, touch or sensory exercises automatically. A quiet environment may be more helpful than a traditional five-senses exercise.
Visual snow syndrome (VSS)
What can overlap?
Visual discomfort, concentration problems, distress and sometimes a sense of unreality.
What may differ?
VSS typically involves persistent tiny flickering dots across the visual field in both eyes, often with afterimages, light sensitivity or night-vision difficulty.
This is different from reliving a traumatic scene. It is also distinct from typical temporary migraine aura.
What may help?
Arrange eye/neurological assessment to exclude other causes. Try comfortable lighting, less glare and short screen breaks.
Some people benefit from individually selected tinted lenses; evidence is limited. There is no established reliably effective treatment.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Briefly notice distress without judging yourself. Acceptance may help with frustration about persistent symptoms while you continue seeking care.
One small example: “The visual symptoms are here. I can make this moment more comfortable.”
Adapt to your needs: You do not need to stare at the visual snow or scan your symptoms. Use a comfortable non-visual anchor if helpful. These skills are not established treatments for VSS.
Conditions that span domains
Some conditions do not fit neatly into the six areas. They remain important and are shown here rather than assigned a single explanation.
ME/CFS / post-exertional malaise (PEM)
What can overlap?
Exhaustion, poor sleep, concentration difficulties and reduced participation.
What may differ?
Disproportionate worsening after exertion, sometimes delayed and lasting days or longer, is characteristic of PEM. It does not require a trauma reminder.
What may help?
Use flexible pacing within current energy limits. Break tasks into smaller parts and avoid fixed activity increases where PEM is present.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Balance wishes with current capacity. Prepare a short plan for stopping, asking for help and recovering after an appointment.
One small example: “I want to attend, and my energy is limited. I will shorten the visit.”
Adapt to your needs: Thinking, conversation and skill practice also use energy. Keep practice brief; rest is a valid choice. Build Mastery does not require activity increases.
Functional neurological disorder (FND)
What can overlap?
Weakness, shaking, altered sensation, seizure-like episodes and sometimes dissociation.
What may differ?
FND is diagnosed using positive clinical features, not simply normal tests or a trauma history. Trauma is not required and other neurological conditions may coexist.
What may help?
Ask for a clear explanation of the diagnosis and tailored rehabilitation. Address pain, fatigue or trauma where relevant without assuming one cause.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Combine your symptom plan with practical choices and rehearse how to request help. Skills may support coexisting distress or emotion regulation difficulties.
One small example: “These symptoms are real. I can follow my agreed plan and tell others what helps.”
Adapt to your needs: DBT is not a universal treatment for FND. Coordinate skills with your treating team; grounding or attention to symptoms can be unhelpful for some people.
Sleep apnoea
What can overlap?
Waking alarmed, poor sleep, fatigue and brain fog.
What may differ?
Snoring, witnessed breathing pauses and gasping suggest a breathing-related sleep problem. A sleep study may be appropriate; nightmares alone do not distinguish causes.
What may help?
Ask about sleep assessment. Use prescribed treatment and review fit or comfort problems rather than abandoning treatment unsupported.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Treat physical illness and plan a manageable bedtime routine, including prescribed sleep-apnoea treatment. Prepare a request for help with mask discomfort.
One small example: “I will set up my prescribed equipment and ask the sleep team about the fit.”
Adapt to your needs: DBT does not correct airway obstruction. Breathing exercises are not a substitute for CPAP or other prescribed treatment.
Vocal cord dysfunction / inducible laryngeal obstruction
What can overlap?
Throat tightness, breathlessness and panic.
What may differ?
Episodes involve altered laryngeal function, often difficulty breathing in. Assessment may include viewing the larynx. Fear during an episode does not establish its cause.
What may help?
Seek respiratory/ENT assessment and specialist speech-therapy breathing techniques. Use your agreed plan; new or severe breathing symptoms need urgent care.
DBT skills that may help
Choose a skill for a short explanation.
How they may help: Prepare and follow the breathing plan taught by your specialist. A brief pause may help you access that plan when fear rises.
One small example: “I will use my clinician-taught technique and seek help if the episode is severe.”
Adapt to your needs: Generic deep breathing, breath-holding or paced breathing may not suit you. Use specialist guidance; never delay urgent assessment to complete a skill.
Choose one manageable next step
Notice one episode: What happened beforehand? Were you upright, exerting yourself, exposed to a particular sound, having visual symptoms or reminded of a frightening experience?
Bring a brief example: Describe timing, other symptoms, duration and what helped. Do not deliberately provoke symptoms.
Adapt the plan: Pacing and sensory protection should not automatically be labelled fear-based avoidance. Therapy and activity plans need to consider PEM, pain, autonomic and sensory limits.
Improvement with therapy, rest or medication alone does not establish the original cause.
When symptoms need urgent assessment
New or severe chest pain, severe breathing difficulty, collapse or sudden stroke-like symptoms require urgent help. Call 000 in Australia. Follow an anaphylaxis emergency plan where applicable.
Sudden vision loss, a new curtain or shadow, new flashes with many floaters, or a sudden major visual change needs urgent assessment. Do not assume it is visual snow or migraine.
A short guide to the skills
Open only the skill you want.
STOP — pause before acting
Stop; take a step back; observe; proceed mindfully. Stepping back can mean pausing a reply or reducing demands. Attend to urgent medical needs immediately.
Wise Mind — feelings, facts and needs
Consider what you feel, what you know and what matters. Ask: “What is the safest, most helpful next step within my capacity?” You do not have to feel calm to choose wisely.
Mindfulness / One-mindfully — one thing at a time
Notice one manageable part of the present without judging yourself. Try one short task or a comfortable external anchor. Body scans, breath focus and long practice are optional.
Self-soothe — choose tolerable comfort
Choose one comfort that suits your body and senses: perhaps soft fabric, quiet or a familiar object. Avoid scents, sounds, tastes or touch that aggravate symptoms.
Cope Ahead — prepare a simple plan
Imagine a likely difficulty and rehearse a helpful response. Write one sentence if imagery is difficult: “If this happens, I will do this or ask this person.”
DEAR MAN — make a clear request
Describe the situation, express its effect, assert your request and explain the benefit. Stay on the request, communicate as confidently as you can and negotiate where appropriate. Written messages, scripts and support people are valid adaptations.
PLEASE — support your physical foundations
Treat physical illness; support regular nourishment; avoid substances that destabilise you; support sleep; and adapt physical activity to your health and capacity. With PEM, stay within energy limits rather than using exercise to push through symptoms.
Accumulate Positive Experiences — a small good moment
Choose a pleasant or meaningful experience that fits your energy and senses. It may be a minute of connection or a familiar comfort. It does not require feeling positive or ignoring grief.
Build Mastery — an achievable success
Choose something manageable that supports a sense of capability. Asking for help or setting up an easier task can count. Success is defined by your needs, not by doing more each day.
Radical Acceptance — acknowledge today’s reality
Recognise what is happening now so you can choose your next response. Acceptance does not mean approval, forgiveness, surrendering care or staying in an unsafe situation.
Self-validation — recognise your experience
Name what you feel and why it makes sense: “This is hard, and I need support.” Validation acknowledges the experience without assuming every interpretation is accurate.
Check the Facts / Opposite Action — use with care
Check an emotional interpretation against available facts without dismissing bodily symptoms.
Opposite Action is for an emotion or urge that does not fit the facts, or is ineffective, when the action is safe. It is not a reason to override PEM, allergy precautions, sensory needs or real danger.
TIPP — some parts need medical adaptation
TIPP includes temperature change, intense exercise, paced breathing and paired muscle relaxation. These are not suitable defaults for everyone.
With PEM, autonomic, respiratory or other medical concerns, choose another skill or discuss specific adaptations with your clinician. Do not use breath-holding, cold-water face immersion or intense exercise automatically.
Reference list & further reading
- Hypermobility spectrum disorders — The Ehlers-Danlos Society
- DBT and its four skill areas — Behavioral Tech Institute
- Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets, second edition. Guilford Press. Skill names and framework; examples on this page are original adaptations.
- PTSD treatment options — VA National Center for PTSD
- POTS — Johns Hopkins Medicine
- ME/CFS symptoms — CDC
- ME/CFS management — NICE NG206
- MCAS — AAAAI
- Migraine — MedlinePlus Genetics
- Fraser (2024): How do I recognise and manage visual snow syndrome?
- Swedo et al. (2022): Consensus definition of misophonia
- Jager et al. (2021): CBT for misophonia—randomised trial
- Hyperacusis — NHS
- Autism — NIMH
- ADHD — NIMH
- Fibromyalgia — NIAMS
- IBS — NIDDK
- Bladder pain syndrome — NIDDK
- Sleep apnoea — NHLBI
- Laryngeal obstruction assessment — North Bristol NHS
- FND: Australian treatment recommendations (2025)
- PTSD — NIMH
- Complex PTSD — NHS
Practical adaptations are options to discuss or try gently, not guaranteed treatments. Evidence and individual responses vary.
Neurodivergence • practical tips
Start with the load. Reduce noise, light, questions or social demands before adding a skill. You do not need to become calm before receiving help.
Choose one tip that fits. Neurodivergent people have different needs.
Sensory overload • reduce input first
Move to a quieter space if possible, dim the light or use familiar sensory supports.
Try: “Less sound. Less talking. One thing at a time.”
For Self-Soothe, choose one tolerable sense. Skip scents, uncomfortable textures or music that adds load.
Headphones, a fidget or familiar movement may help some people. Use only what is comfortable and within your energy limits.
Feelings are hard to name • use simple words
You do not need an exact emotion label. Try “too much”, “uncomfortable”, “not sure” or “I need a change”.
Try: “I cannot name the feeling. I need quiet.”
Use a known need or an external focus instead of searching inside your body. New or concerning bodily symptoms still need appropriate assessment.
Too many steps • make the skill smaller
Use one prompt, one saved phrase or one familiar option. Ask someone to help with setup.
STOP: “Pause. I can decide later.”
Pros & Cons: “What could happen if I act now? What is a safer option?”
You can prepare a short support card when you have capacity. No worksheet is required during overload.
Talking is difficult • use another way
Use writing, a saved message, a gesture or a communication aid. Allow processing time without repeated questions.
Saved message: “I am overloaded. Please reduce questions. I will respond when I can.”
Agree on signals and useful support beforehand if wanted. Eye contact and verbal explanations are optional.
Imagery or inner focus is difficult • use concrete alternatives
For IMPROVE, replace mental imagery with a real photograph, familiar object or written phrase.
Try: “This moment is difficult. One small support is enough.”
Skip body scans or breath focus if they increase distress. You can keep your eyes open and notice something neutral around you.
Shutdown or meltdown • care before coaching
Reduce demands and protect physical safety. Use familiar support and the person’s agreed plan.
For supporters: speak less, allow space and avoid unexpected touch. Ask before touching or moving someone when possible.
Do not demand a skill, an explanation or a decision. Reflection can wait until capacity returns, and only if useful and wanted.
Neurodivergence with PEM • include energy limits
Concentrating, processing sensory input, talking and emotional work can all use energy.
Skip intense exercise. A hobby, distraction or repeated prompting may also be too demanding.
Try: “Please arrange quiet and comfort. I need to rest.”
Use your individual energy-management plan, including delayed effects. Rest does not need to become a mindfulness task.
The aim is support that fits you. Distress tolerance should not require masking, forced eye contact or enduring painful sensory input.
ALPIMS • DBT SKILLS
Distress Tolerance
Get through a difficult moment.
Reduce extra harm. Find support that fits.
You do not have to solve everything now. Choose one skill, a smaller version or practical care.
Start here Back to ALPIMS – DBT
You deserve support while you are distressed.
These skills do not require you to tolerate harmful behaviour,
untreated symptoms or overwhelming sensory input.
What is needed first?
Too much to think? Reduce questions and demands. Use familiar support or your care plan.
A strong urge to act? Try a pause with STOP.
A painful reality? Try a small acceptance statement, when you have capacity.
Immediate danger or urgent medical needs require practical help first. Skills can support you alongside that help.
Getting through an intense moment
Open one box. Read the short version first.
STOP
Pause before acting on an urge.
ACCEPTS
Shift attention for a short while.
TIP / TIPP
Body-based skills for intense emotion.
Self-Soothe
Offer comfort through tolerable senses.
IMPROVE
Make this moment more manageable.
Pros & Cons
Compare an urge with a safer response.
Responding to the situation
When you have room to consider what comes next.
Problem Solving
Change what can be changed.
Radical Acceptance
Acknowledge what is true right now.
Pain, acceptance and suffering
DBT uses the idea that fighting an unchangeable fact can add distress to pain. Acceptance may reduce that extra struggle.
The “pain + acceptance” equations are teaching metaphors, not literal rules. Pain, grief and trauma-related distress may remain despite acceptance. Difficulty accepting is not a moral failure.
You can acknowledge reality and still seek treatment, protection, justice or change.
Practise gently • no perfection needed
When you have capacity, try one suitable skill in a manageable situation. Notice what helps and what makes things worse.
Save a short phrase or prepare one support ahead of time. Familiarity can make access easier during distress.
You do not have to practise daily, build tolerance to harmful input or increase effort. Practising beforehand is helpful, not a condition for receiving care.
Neurodivergence and sensory overload
Reduce sensory load and demands first. Use predictable choices, concrete language and processing time.
Writing, communication aids, a familiar interest or a tolerable fidget may help. Eye contact, stillness and imagery are optional.
During shutdown or meltdown, questions and worksheets may add load. Use the person’s agreed support plan. Sensory protection is part of care.
PEM, brain fog and low energy
Reading, thinking, emotional work and social interaction can use energy and contribute to delayed worsening with PEM.
Skip intense exercise. Use less effort, reduce stimulation and ask someone to arrange practical comfort or care.
A smaller distraction may still be too much. Rest without a task is allowed. Follow individual energy limits, including delayed effects; no fixed increases.
Trauma, panic or dissociation
Preserve choice. Skip inward focus, closed eyes or breathing exercises if they are unsettling.
If helpful, orient to a neutral object, your current surroundings or a familiar person’s voice. Stop if distress or disconnection increases.
Acceptance does not require recounting trauma, forgiving someone or remaining in an unsafe situation.
Optional • Across ALPIMS
These adaptations may support coping and access to care. They are not treatments for the underlying conditions.
A • Anxiety & Autonomic
Use a pause or tolerable comfort alongside appropriate bodily care. Dizziness, palpitations or breathlessness are not automatically anxiety. TIP techniques need individual consideration.
L • Laxity / Connective Tissue
Use supported positioning, joint protection and accessible activities. Skip painful movement or muscle tensing. Practical assistance can reduce distress.
P • Pain / Bodily Sensitivity
Reduce light, sound or other demands when helpful. Use prescribed care plans and ask for support. Distress tolerance does not mean enduring untreated pain.
I • Immune / Inflammatory
Respect known allergies and relevant triggers. Skip fragrance, problematic foods or cold exposure where unsuitable. Necessary treatment and environmental protection come first.
M • Mood / Mental Health
A pause, temporary distraction or pros and cons may help with strong urges. Use suitable mental health support. Persistent or escalating distress needs more than a coping worksheet.
S • Sensory / Neurodevelopmental
Adapt communication and reduce sensory input. Offer one option and time to respond. Do not use skills to demand masking or endurance of painful sensations.
For families and supporters
Ask what help is welcome. Offer one simple option: “Would quiet or help with care be useful?” Accept “neither”, “later” or no answer.
Provide practical support and respect consent. Do not demand calm before care or use acceptance to avoid accountability.
Reflect later only if wanted and within capacity.
Sources and scope
Distress tolerance skills come from DBT developed by Marsha Linehan. The ALPIMS, neurodivergence and energy-sensitive examples here are educational adaptations, not a separately validated programme.
- Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets, second edition. Guilford Press. Distress Tolerance handouts.
- NICE NG206: ME/CFS energy management .
- VA: coping with traumatic stress reactions .
- DBT.tools: general distress tolerance resources . Some standard physical and sensory suggestions require adaptation.
DBT emphasizes learning to bear pain skillfully because pain and distress are part of life and cannot be entirely avoided. Tolerance is necessary during any behavior change because impulsive behavior would interfere. Distress tolerance is the ability to perceive the environment as it is, without demanding that it be different.
pain + non-acceptance = suffering
pain + acceptance = ordinary pain
Practice Makes Perfect
Distress Tolerance Skills are meant to help us survive crisis, but they need to be practiced before a crisis occurs. These skills are helpful when we cannot sort out our emotions. These skills are to be used when a crisis cannot be avoided. An important concept is acceptance of reality. Read more about each of these skills by selecting one from below:
ACCEPTSTIPSelf-SootheImprovePros/ConsProblem SolvingRadical Acceptance