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Abstract

The paper forms part of a series of two papers outlining the theoretical framework for a new model of uncertainty distress (paper one) as well as treatment implications (paper two) arising from the model. We define uncertainty distress as the subjective negative emotions experienced in response to the as yet unknown aspects of a given situation. In the first paper we drawn on a robust body of research on distinct areas including: threat models of anxiety, perceived illness uncertainty and intolerance of uncertainty. We explore how threat and uncertainty are separable in anxiety and how we can understand behaviours in response to uncertainty. Finally, we propose a clinically, theoretically and empirically informed model for uncertainty distress and outline how this model can be tested. Clinical applications and practitioner key points are briefly included, however these are more fully outlined in our treatment implications (paper two). While we outline this model in the context of novel coronavirus (Covid-19), the model has broader applications to both mental and physical health care settings.

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... Regarding the COVID-19 pandemic, uncertainty concerns the unpredictability of the future (i.e., the inability to predict the course of the disease and its related events) as much as the limited ability to exert control over the situation. Facing situations of uncertainty, some individuals might experience "uncertainty distress", defined by Freeston, Tiplady, Mawn, Bottesi, and Thwaites (2020) as "the subjective negative emotions experienced in response to the as yet unknown aspects of a given situation". This distress due to uncertainty could, in turn, render individuals intolerant to uncertainty. ...
... This seems in accordance with the literature on identity which indicates that personal growth requires efforts to integrate new and different roles or experiences in a whole coherent identity (Diehl & Hay, 2011). Regarding intolerance of uncertainty, it seems relevant to dive back in Freeston et al. (2020) who distinguished the trait of being intolerant to uncertainty to the emotional state of being distressed due to uncertainty. The current study has been conducted during the second month of the pandemic. ...
... The second aim of the present study was to assess the extent to which (1) emotion regulation strategies, (2) intolerance of uncertainty and, (3) environmental satisfaction are significant predictors of both negative and positive emotions. While these relationships have already been investigated in previous studies (Balzarotti et al., 2016;Freeston et al., 2020;Wagener & Blairy, 2015), their assessment in the specific pandemic's context remains relevant. Indeed, these relationships might appear modified which, in turn, could implicate adjustments in clinical practice. ...
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The COVID-19 pandemic has been shown to induce several psychological consequences (e.g., increases in anxiety and stress). Accordingly, it seems relevant to investigate how individuals cope with their emotions. Indeed, when facing negative emotions, individuals need to rely on adaptive emotion regulation strategies to alleviate their negative impacts (e.g., decrease in quality of life, increase in sleep disturbances). Moreover, lockdown's measures led to a restriction of the access to activities which, in turn, might have decreased the "environmental satisfaction". Then, this research investigates the pandemic's psychological impacts on emotions and regulation strategies, intolerance of uncertainty, and environmental satisfaction. Our approach's originality relies on comparing one's actual psychological functioning (i.e., since the pandemic) to one's general psychological functioning (i.e., before the pandemic). This study also assesses the relationships between both negative and positive emotions and (1) emotion regulation strategies, (2) intolerance of uncertainty and, (3) environmental satisfaction since the pandemic and its lockdown. The total sample comprised 948 adults from the general population. Results show that, since the pandemic, individuals experience higher levels of negative emotions, lower levels of positive emotions and environmental satisfaction. They also tend to worry less and to resort to acceptance more often. Also, environmental satisfaction is the most important predictor of both negative emotions and positive ones. Overall, findings confirm previous ones and seem to indicate that environmental satisfaction should be addressed more thoroughly.
... Originally examined predominantly in its relationship to generalized anxiety disorder (GAD), IU is now recognized as a potential transdiagnostic vulnerability factor associated with a range of mental health problems, including anxiety conditions and posttraumatic stress disorder (PTSD; Bardeen et al., 2013;Freeston et al., 2020;Rettie & Daniels, 2020;Rosser, 2019;Shihata et al., 2016). IU is defined as a dispositional tendency to experience an aversion to situations or events in which the outcome is yet unknown but might be knowable in the foreseeable future (Freeston et al., 2020;Shihata et al., 2016). ...
... Originally examined predominantly in its relationship to generalized anxiety disorder (GAD), IU is now recognized as a potential transdiagnostic vulnerability factor associated with a range of mental health problems, including anxiety conditions and posttraumatic stress disorder (PTSD; Bardeen et al., 2013;Freeston et al., 2020;Rettie & Daniels, 2020;Rosser, 2019;Shihata et al., 2016). IU is defined as a dispositional tendency to experience an aversion to situations or events in which the outcome is yet unknown but might be knowable in the foreseeable future (Freeston et al., 2020;Shihata et al., 2016). When faced with uncertainty, or a psychological state of not knowing aspects of a given situation (Freeston et al., 2020;Kuang, 2017), individuals with high IU may experience heightened distress and respond to the situation's aversiveness by engaging in behaviours intended to reduce uncertainty and related distress, such as through reassurance seeking, self-distraction, and avoidance-like behaviors (Einstein, 2014;Freeston et al., 2020;Rettie & Daniels, 2020). ...
... IU is defined as a dispositional tendency to experience an aversion to situations or events in which the outcome is yet unknown but might be knowable in the foreseeable future (Freeston et al., 2020;Shihata et al., 2016). When faced with uncertainty, or a psychological state of not knowing aspects of a given situation (Freeston et al., 2020;Kuang, 2017), individuals with high IU may experience heightened distress and respond to the situation's aversiveness by engaging in behaviours intended to reduce uncertainty and related distress, such as through reassurance seeking, self-distraction, and avoidance-like behaviors (Einstein, 2014;Freeston et al., 2020;Rettie & Daniels, 2020). Although these actions may temporarily increase a sense of certainty and reduce distress, uncertainty-reducing behaviours can strengthen IU over time, increasing both perceived uncertainty and perceived threat to uncertain situations, and heightening uncertainty distress, such as anxiety and worry (Freeston et al., 2020;Pepperdine et al., 2018). ...
Preprint
Amidst the ongoing COVID-19 pandemic, people are facing heightened uncertainty about the future and increasing rates of psychological distress. Intolerance of uncertainty (IU) and perceived COVID-19 threat may be contributing to mental health problems. This study investigated changes in mental health problems prior to and during the first two pandemic waves in the U.S., and the extent to which IU and perceived COVID-19 threat predicted these problems. MTurk participants (n=192; 50% women) were recruited from a pre-pandemic study in December 2019/January 2020 for a follow-up study on COVID-19 experiences, across five timepoints between April and August 2020. IU, perceived COVID-19 threat, and mental health problems (i.e., worry, COVID-19 fear, and trauma symptoms) were assessed. On average, mental health problems were not elevated, relative to pre-pandemic levels, and remained stable across time. Heightened IU and perceived COVID-19 threat were associated with more mental health problems. Surprisingly, objective measures of COVID-19 threat (e.g., state case rates) showed no associations with IU, and were slightly negatively correlated with psychological distress and perceived threat. Pre-existing mental health symptoms, IU and perceived COVID-19 threat may foster vulnerability to mental health problems during the pandemic, more so than objective threat levels.
... "Intolerance of uncertainty" (IU) is a psychological concept most notably examined as a key maintaining factor within generalized anxiety disorder. However, with more recent research suggesting IU is a concept found across many emotional disorders (e.g., Carleton et al., 2012;Carleton et al., 2014;Fergus & Bardeen, 2013;Holaway, Heimberg, & Coles, 2006), transdiagnostic models of IU have been established (Einstein, 2014;Freeston, Tiplady, Mawn, Bottesi, & Thwaites, 2020). ...
... Individuals in vulnerable groups were not significantly different in their ability to tolerate uncertainty than the rest of the general population, which may be attributed to an adapted tolerance of uncertainty when living with a longterm health condition (Kurita, Garon, Stanton, & Meyerowitz, 2013). Freeston et al.'s (2020) model of uncertainty distress suggests that alongside IU, "perceived threat" (i.e., degree to which one feels under threat) independently contributes to psychological distress. Thus it could be that for physically vulnerable individuals, it is the perceived (and arguably realistic) increase in threat, rather than their overall ability to tolerate uncertainty, that contributes to their increased levels of psychological distress. ...
... Current evidence-based models of cognitive-behavioral therapy for generalized anxiety (National Institute for Health and Care Excellence, 2011), depression (National Institute for Health and Care Excellence, 2009), and health anxiety (Salkovskis et al., 2003) may benefit from adaptation to incorporate IU and patterns of coping as discussed herewith. For example, from both our results and proposed models of uncertainty distress (Freeston et al., 2020) it could be theorized that individuals who are struggling with their mental health may find uncertainty difficult to manage, and may be more likely to be using maladaptive coping strategies such as self-distraction as a result. Maladaptive strategies such as these can perpetuate distress by preventing disconfirmation of the feared outcome (Salkovskis et al., 2003). ...
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The current pandemic wave of COVID-19 has resulted in significant uncertainty for the general public. Mental health and examining factors that may influence distress have been outlined as key research priorities to inform interventions. This research sought to examine whether intolerance of uncertainty and coping responses influence the degree of distress experienced by the U.K. general public during the COVID-19 pandemic. Using a cross-sectional online questionnaire design, participants were recruited (N = 842) using snowball sampling over a 10-day period in the early "lockdown" phase of the pandemic. Around a quarter of participants demonstrated significantly elevated anxiety and depression, with 14.8% reaching clinical cutoff for health anxiety. A one-way multivariate analysis of variance indicated those in "vulnerable" groups were significantly more anxious (p < .001), and also more anxious in relation to their health (p < .001). Mediation modeling demonstrated maladaptive coping responses partially mediated the predictive relationship between intolerance of uncertainty and psychological distress. Mental health difficulties have become significantly raised during the first wave of the COVID-19 pandemic in the United Kingdom, particularly for the vulnerable. Findings support emerging research suggesting the general public is struggling with uncertainty, more so than normal. Vulnerable groups are more anxious about their health, but not more intolerant of uncertainty than the nonvulnerable. Finally, this study indicated two modifiable factors that could act as treatment targets when adapting interventions for mental health during the COVID-19 global health crisis. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
... The effects of threats and losses on EWB also may differ. The uncertainty distress model posits that uncertainty is a main cause of distress, even in low-threat situations [31]. Thus, its effect may differ from that of loss, which brings "complicated grief" [6]. ...
... However, threats are less devastating. If faced with the threat of losing economic, social, and health capital [20,23], with all the uncertainty and distress evoked by COVID-19 [31], and hope may prevail, and even if new resources are required, fewer are needed. Threat also may be reinterpreted as a challenge [48] and regarded as a coping strategy: coping requires one to recognize a threat and to decide how to treat the situation [27]. ...
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Article
This paper used Hobfoll’s conservation of resources theory as a theoretical framework to investigate which kinds of resource loss predicted the emotional well-being (EWB) of ethnic minorities and majority populations during a period of crisis. Data were collected from a national representative survey conducted by the Israel Central Bureau of Statistics during the COVID-19 pandemic. The sample inclu`ded 1157 respondents, including 174 Israeli Palestinian citizens (ethnic minority) and 983 Israeli Jews (majority population). Measures of EWB, actual losses and threats of losses of economic, social, and health resources were examined. The results showed that the losses of economic, social, and health resources reduced the EWB of individuals. Negative effects of the actual losses of resources on EWB were greater than those of the perceived threats of loss. The largest effect was for economic resources. There were differences in effects between the ethnic minorities and the majority populations. The study revealed that for the ethnic minorities, who are less powerful and more disadvantaged than ethnic majorities, the depletion of already deficient resources during time of crisis is more important for predicting their EWB than for the majority populations.
... Uncertainties about how long the COVID-19 pandemic will last (Gica et al., 2020;Glowacz & Schmits, 2020), how the virus is being transmitted (McKay et al., 2020), how long government restrictions will last (Rettie & Daniels, 2020), what will happen due to limited tests during the pandemic (Mertens et al., 2020), and what will happen in the future (Larsen et al., 2020) are some of the questions raised by researchers, scientists, and the public. These questions illustrate the uncertainty of the pandemic (Freeston et al., 2020;Koffman et al., 2020) and may be troubling for many individuals (Arpaci et al., 2021), especially for those with low tolerance of certainty. Intolerance of uncertainty is a cognitive bias that affects how individuals perceive, interpret, and react to uncertain situations at behavioral, mental, and emotional levels (Dugas et al., 2005). ...
... Intolerance of uncertainty is a cognitive bias that affects how individuals perceive, interpret, and react to uncertain situations at behavioral, mental, and emotional levels (Dugas et al., 2005). Intolerance of uncertainty is also defined as subjective negative emotions experienced in response to unknown aspects of a situation (Carleton, 2012;Freeston et al., 2020). During the COVID-19 pandemic, intolerance of uncertainty increases due to changes in daily routines (Satici et al., 2020). ...
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Article
There is an emerging literature on the mental and physical exhaustion due to the COVID-19 related restrictions. Some individuals seem to exercise fewer precautions recently in comparison to the onset of the pandemic in preventing the spread of the COVID-19. This phenomenon is described as pandemic fatigue. Though acknowledged in conceptual articles and news reports, there is a lack of empirical evidence pertaining to pandemic fatigue. We collected data from 516 adult participants to investigate pandemic fatigue and its relations to fear of coronavirus, intolerance of uncertainty, apathy, and self-care. 34.40% of the participants reported that the level of COVID-19-related precautions they take have decreased in comparison to measures they took at the onset of the pandemic. Additionally, our model examining the role of fear of coronavirus, intolerance of uncertainty, and apathy as mediated by self-care predicting pandemic fatigue demonstrated acceptable to excellent goodness-of-fit indices. The fact that one in every three individuals is taking fewer precautions is not only a threat to the individuals' own health but also to the public. Given that individuals are experiencing pandemic fatigue, governments should consider paying more attention to the biopsychosocial nature of humans in ordering restrictions and planning necessary precautions. Supplementary information: The online version contains supplementary material available at 10.1007/s12144-021-02397-w.
... The intolerance of uncertainty is considered a state of mind in the face of anxiety [70]. In addition, uncertainty-tolerant referral cases have also been established [71]. The model states that the intolerance of uncertainty also indirectly causes some degree of stress. ...
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Since the end of 2019, COVID-19 has continued to spread around the world. The police have performed various epidemic prevention and routine duties. This study explores how police officers’ COVID-19 fear, resistance to organizational change, intolerance of uncertainty, and secondary trauma affect emotional exhaustion and insomnia in the context of COVID-19. A total of 205 valid police samples were collected in this study, and the established hypotheses were tested using confirmatory factor analysis and structural equation modeling. The results of the study confirmed that during the COVID-19 outbreak, secondary trauma of police officers positively affects emotional exhaustion and insomnia; intolerance of uncertainty positively affects emotional exhaustion; resistance to organizational change positively affects intolerance of uncertainty and emotional exhaustion; intolerance of uncertainty mediates the relationship between resistance to organizational change and emotional exhaustion; COVID-19 fear positively influences secondary trauma.
... In the context of COVID-19, individuals with a higher intolerance of uncertainty levels may search for medical information to reduce uncertainty that results in additional negative experience [55][56][57]. Intolerance of uncertainty amplifies both threat perception and uncertainty perception [58], which can lead to more engagement in safety behaviors (eg, checking behavior) [59]. Like a vicious circle, seeking health-related information on the internet to reduce uncertainty may be associated with greater levels of uncertainty and therefore amplify health anxiety. ...
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Article
Background: Studies have highlighted that fear and anxiety generated by COVID-19 are important psychological factors that affect all populations. There currently remains a lack of research on specific amplification factors regarding fear and anxiety in the context of the COVID-19 pandemic. Despite established associations between anxiety sensitivity, intolerance of uncertainty, and cyberchondria, empirical data investigating the associations between these three variables, particularly in the context of the COVID-19 pandemic, are currently lacking. Urgent research is needed to better understand the role of repeated media consumption concerning COVID-19 in amplifying fear and anxiety related to COVID-19.
... In the context of COVID-19, individuals with a higher intolerance of uncertainty levels may search for medical information to reduce uncertainty that results in additional negative experience [55][56][57]. Intolerance of uncertainty amplifies both threat perception and uncertainty perception [58], which can lead to more engagement in safety behaviors (eg, checking behavior) [59]. Like a vicious circle, seeking health-related information on the internet to reduce uncertainty may be associated with greater levels of uncertainty and therefore amplify health anxiety. ...
Full-text available
Article
Background: Studies have highlighted that fear and anxiety generated by COVID-19 are important psychological factors that affect all populations. There currently remains a lack of research on specific amplification factors regarding fear and anxiety in the context of the COVID-19 pandemic. Despite established associations between anxiety sensitivity, intolerance of uncertainty, and cyberchondria, empirical data investigating the associations between these three variables, particularly in the context of the COVID-19 pandemic, are currently lacking. Urgent research is needed to better understand the role of repeated media consumption concerning COVID-19 in amplifying fear and anxiety related to COVID-19.
... In the context of COVID-19, individuals with a higher intolerance of uncertainty levels may search for medical information to reduce uncertainty that results in additional negative experience [55][56][57]. Intolerance of uncertainty amplifies both threat perception and uncertainty perception [58], which can lead to more engagement in safety behaviors (eg, checking behavior) [59]. Like a vicious circle, seeking health-related information on the internet to reduce uncertainty may be associated with greater levels of uncertainty and therefore amplify health anxiety. ...
Full-text available
Article
Background: Studies have highlighted that fear and anxiety generated by the coronavirus disease 2019 (COVID-19) are important psychological factors that affect all populations studied. There is currently still a lack of research on specific amplification factors regarding anxiety and fear in the context of the COVID-19 pandemic. Despite established associations between anxiety sensitivity, intolerance of uncertainty, and cyberchondria, there is currently a lack of empirical data that has investigated the associations between anxiety sensitivity, intolerance of uncertainty, and cyberchondria, particularly in the context of the COVID-19 pandemic. Urgent research is needed to better understand better the role of repeated media consumption concerning COVID-19 in amplifying fear of COVID-19 and COVID-19 anxiety. Objective: The present study investigated the associations between fear of COVID-19, COVID-19 anxiety, and cyberchondria. Methods: A convenience sample of 694 respondents (343 males, 351 females) completed an online survey that included the Cyberchondria Severity Scale, Fear of COVID-19 Scale, Coronavirus Anxiety Scale, Anxiety Sensitively Scale, and Intolerance of Uncertainty Scale. Multiple mediation analyses were conducted using structural equation modeling. Results: The results showed that Fear and anxiety generated by COVID-19 predicted cyberchondria: β=.39, SE=.04, P<.001, t=11.16, 95% CI [0.31, 0.45] and β=.25, SE=.03, P<.001, t=7.67, 95% CI [0.19, 0.32], respectively. Also, intolerance of uncertainty and anxiety sensitivity mediated the relationship between fear and anxiety generated by COVID-19 with cyberchondria. In reciprocal model, the standardized total effects of the cyberchondria on fear of COVID19 (β = .45, SE=.04, P<.001, t= 15.31, 95% CI [0.39, 0.51]) and COVID-19 anxiety (β = .36, SE=.03, P<.001, t= 11.29, 95% CI [0.30, 0.41]) were statistically significant, with moderate effect sizes. Compared to males, females obtained statistically significantly higher scores of cyberchondria (t[692]=-2.85, P=.004, Cohen's d=.22), COVID-19 anxiety (t(692)=-3.32, P<.01, Cohen's d=.26), and anxiety sensitivity (t[692]=-3.69, P<.001, Cohen's d=.29). Conclusions: The findings provide further support in better understanding the role of COVID-19 in amplifying cyberchondria. Finally, based on the findings here, cyberchondria must be viewed as a significant public health issue. Importantly, increasing awareness about cyberchondria and online behavior at both individual and collective levels must be prioritized to enhance preparedness and to reduce adverse effects of current and future medical disasters. Clinicaltrial:
... morbidity (Carleton et al. 2012;Freeston et al. 2020;Mertens et al. 2020;Sankar et al. 2017;Sim and Chua 2004). Intolerance of uncertainty, namely the difficulty of not knowing, is associated with other mental health problems (Glowacz and Schmits 2020, including generalized anxiety disorder (Boswell et al. 2013;Rosser 2019) and depression (Carleton et al. 2012;Gentes and Ruscio 2011). ...
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Article
The COVID-19 pandemic has led to governments taking a number of restrictive measures. Confinement at home during the COVID-19 crisis could have major implications on mental health and alcohol use behaviors among the whole population. The present study focuses on the role of individual characteristics, contextual factors, and mental health variables on alcohol consumption. A sample of 2871 adults (79% women) were recruited from the general population through an online self-report questionnaire. Sociodemographic data, lockdown conditions, occupational/physical activity, proximity of contamination, mental health (anxiety, depression, and intolerance of uncertainty), and alcohol consumption (frequency, quantity, and changes) have been assessed. Among participants, 49.1% of the population reported stable alcohol consumption, 24.5% reported a decreased in alcohol consumption since the beginning of the lockdown and 26.4% reported an increase in consumption. Our findings indicate that those individuals who increased their alcohol consumption during the lockdown are often older, working from home, more likely to have children, higher educated, and consume alcohol more frequently and in higher quantities. They also have a greater proximity to contamination and higher levels of anxiety and depression. Our results are discussed in terms of preventive implications.
Article
Co-morbid mental health diagnoses present challenges for services structured to provide disorder-specific models of treatment, such as those structured around Improving Access to Psychological Therapies (IAPT). Intolerance of uncertainty (IU) has been identified as both disorder specific and transdiagnostic, although little research explores transdiagnostic approaches to treatment of IU alone. A cognitive behavioural therapy treatment targeting IU previously established for individual therapy was adapted for a group within an IAPT primary care service: the ‘Making Friends with Uncertainty’ (MFWU) group. Twenty patients presenting with symptoms of a range of disorders including generalised anxiety disorder, obsessive compulsive disorder and depression completed the intervention in three groups. Measures of IU, anxiety and depression administered in the first and final sessions of the group have been analysed as well as examining common themes in participant feedback and facilitators’ own reflections. The results showed that nine participants (45%) showed reliable change in IU following the group and 16 (80%) showed reliable change on a measure of depression or anxiety. A thematic analysis identified universality, tolerance and acceptance and the manifestation of IU in the group process as key. The results suggest that the MFWU group provides an effective and feasible option for individuals presenting to IAPT services, including those reporting co-morbid difficulties. Implications for future practice are discussed as iteration and evaluation of the framework and content will continue. Key learning aims (1) To gain an overview of a transdiagnostic model of IU. (2) To develop understanding of a group intervention for building tolerance to uncertainty. (3) To describe some group processes observed and learn from the delivery of a transdiagnostic group intervention. (4) To consider applications of transdiagnostic treatment in a group setting in IAPT. (5) To understand how to structure a group treatment for IU, and which factors to consider.
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To control the COVID-19 pandemic, governments have implemented restrictions. This study evaluates psychological distress related to the crisis and identifies predictive factors of anxiety/depression according to age. 2,871 adults were recruited through an online questionnaire during the lockdown. Three subsamples were identified: 18–30; 30–50; > 50 years. The population suffers from anxiety and depression. Young adults adu reported lower levels of living space, occupational activity, social contact and alcohol use, but higher anxiety, depression and uncertainty than older participants. This psychological distress can be explained by lockdown conditions (differently according to age) and by intolerance to uncertainty. Also, youth's alcohol intake has decreased. Deconfinement strategies have been discussed.
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This review assesses various sources regarding obsessive-compulsive disorder (OCD) symptoms and the coronavirus pandemic via a study of literature related to OCD conditions in the United States, China, the United Kingdom, and India. Coronavirus's morbidity and its status as a global pandemic transmittable from one person to another has subsequently intensified the personal perception of distress. The projected shortage of vital medical equipment to fight coronavirus due to daily increases in COVID-19 cases creates social unrest. The world confronts perpetual news about high numbers of corona-virus cases, more people in quarantine, and more deaths; those not infected feel increasing fear about its proximity. Social media, print media, and electronic sources offer much advice on how to prevent coronavirus infection. Pandemics extend beyond pathophysiology and medical phenomena to associations with intense psychosocial impact. Studies have established that people with existing mental disorders are prone to relapses, the fear of faulty COVID-19 prevention measures, distress, and suicidal thoughts during pandemics. Precautionary measures aim to slow the spread of coronavirus, but these radical repetitive measures create great anxiety in the mental health of individuals suffering from OCD. Despite the nature of their conditions, these people must adhere to routine processes, such as washing hands, wearing masks and gloves, and sanitizing hands. Given the asymptomatic nature of people suffering from OCD, the routine measures for addressing COVID-19 have a hectic and adverse effect on their mental health and their state of relaxation. Through a systematic literature review, this paper provides insight into the coronavirus pandemic's implications for OCD symptoms.
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The worldwide coronavirus pandemic has forced health services to adapt their delivery to protect the health of all concerned, and avoid service users facing severe disruption. Improving Access to Psychological Therapies (IAPT) services in particular are having to explore remote working methods to continue functioning. Australian IAPT services have utilised remote delivery methods and disruptive technologies at their core from inception. This was to maintain fidelity and clinical governance across vast distances but has allowed training, supervision and service delivery to continue virtually uninterrupted through coronavirus restrictions. On this basis, key recommendations for remote working are outlined. Remote methods are defined as (1) real time delivery, (2) independent delivery and (3) blended delivery. These are applied across three broad areas of remote training, remote clinical supervision and remote service delivery. Recommendations may be of great benefit to IAPT training institutions, clinical supervisors and service providers considering a move towards remote delivery. Challenges, adaptations and examples of applying remote methods are outlined, including case examples of methods applied to low-intensity and high-intensity cognitive behavioural therapy. Remote methods can safeguard service continuity in times of worldwide crisis and can contribute to reducing the impact of increased mental health presentations post-COVID-19. Key learning aims (1) To understand the core areas of remote training, clinical supervision and service delivery. (2) To review and distinguish between three broad methods of remote working. (3) To understand how to plan remote working via key recommendations and case examples.
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The paper forms part of a series of papers outlining the theoretical framework for a new model of uncertainty distress (this paper), treatment implications arising from the model, and empirical tests of the model. We define uncertainty distress as the subjective negative emotions experienced in response to the as yet unknown aspects of a given situation . In the first paper we draw on a robust body of research on distinct areas including: threat models of anxiety, perceived illness uncertainty and intolerance of uncertainty. We explore how threat and uncertainty are separable in anxiety and how we can understand behaviours in response to uncertainty. Finally, we propose a clinically, theoretically and empirically informed model for uncertainty distress, and outline how this model can be tested. Caveats, clinical applications and practitioner key points are briefly included, although these are more fully outlined in the treatment implications article. While we outline this model in the context of novel coronavirus (COVID-19), the model has broader applications to both mental and physical health care settings. Key learning aims (1) To define the concept of uncertainty distress. (2) To understand the role of threat, over-estimation of threat, perceived uncertainty, actual uncertainty, and intolerance of uncertainty in distress maintenance. (3) To understand how people may behave in response to uncertainty distress. (4) To describe a model of uncertainty distress.
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Background The looming cognitive style (LCS) is a cognitive bias to interpret and generate mental scenarios (i.e., mentally simulate) of threats as rapidly developing and approaching. A rapidly growing and approaching threat is likely to evoke a greater experience of urgency and anxiety in individuals compared to a threat that is interpreted to be static. Individuals who possess the LCS tend to perceive mentally simulated threats as rapidly intensifying and approaching, and this future-oriented prospection (or future-oriented thinking) is assumed to put them at risk of anxiety and depression.Methods The current meta-analytic review examined the strength of the relations between the LCS and different subtypes of anxiety (i.e., nonspecific anxiety, social anxiety, obsessions-compulsions, fears, and worry) and depression. Articles were retrieved from online databases and unpublished data sets. A total of 141 effect sizes were obtained from 61 articles with 69 independent samples after selection criteria were met.ResultsRandom- and mixed-effects models indicated significant mean effect sizes of moderate magnitude. The relations between LCS and the anxiety subtypes were generally significantly stronger than that of depression, in particular for nonspecific anxiety, social anxiety, and worry. Additionally, sample type and study quality emerged as significant moderators for the effect sizes for certain symptoms.Conclusions These results support the idea that LCS is a transdiagnostic vulnerability factor for various anxiety subtypes and that it is more specific to anxiety than to depression. Clinical implications and future directions are discussed.
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Background: The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference. Methods: From 31 January to 2 February 2020, we conducted an online survey using snowball sampling techniques. The online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with COVID-19, knowledge and concerns about COVID-19, precautionary measures against COVID-19, and additional information required with respect to COVID-19. Psychological impact was assessed by the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety and Stress Scale (DASS-21). Results: This study included 1210 respondents from 194 cities in China. In total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). Specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05). Conclusions: During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID-19 epidemic.
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Psychophysiology is a central hub connecting neurobiological and behavioral domains with clinical science, thus providing ideal tools for increasing the understanding of mental disorders beyond the level of symptom reports. The present article provides an overview of how psychophysiological research can contribute toward efforts directed at an improved understanding of anxiety disorders. Starting with the behavioral domain, it is demonstrated that defensive behaviors are fundamental to anxiety disorders and that these behaviors are dynamically organized depending upon the proximity of a specific threat. The next section reviews neural networks that are activated during the encoding of threat‐relevant information and during the organization of the cascade of defensive responses, including how passive avoidance might be conceptualized within a neurobehavioral framework. The last section addresses the translation of these behavioral and neuronal findings from experimental psychopathology research to clinical populations. Finally, evidence is presented to support how behavioral approaches may be helpful in predicting treatment outcomes. In clinical science, psychopathology is often categorized using fine‐grained criteria, primarily based on patient's symptom reports. The current article provides a more mechanism‐based approach for understanding psychopathology of anxiety disorders. First, a model of dynamic organization of defensive behaviors derived from animal research is introduced, which might serve as a useful theoretical background. Empirical evidence is presented, showing that encoding of threat information and organization of defensive behaviors including the accompanying physiological adjustments is also dynamically organized in humans. In the final part, the theoretical model is used to better understand psychopathology in patients with anxiety disorders.
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Intolerance of Uncertainty is a trans-diagnostic process that spans a range of emotional disorders and it is usually measured through the Intolerance of Uncertainty Scale-12. The current study aims at investigating some issues in the assessment of Intolerance of Uncertainty (IU) through the Italian Intolerance of Uncertainty Scale-Revised, a measure adapted from the Intolerance of Uncertainty Scale-12 to assess IU across the lifespan. In particular we address the factor structure among a large community sample, measurement invariance across gender, age, and over time, together with reliability and validity of the overall scale and its subscales. The questionnaire was administered to community (N = 761; mean age = 35.86 ± 14.01 years) and undergraduate (N = 163; mean age = 21.16 ± 2.64 years) participants, together with other self-report measures assessing constructs theoretically related to IU. The application of a bifactor model shows that the Italian Intolerance of Uncertainty Scale-Revised possesses a robust general factor, thus supporting the use of the unit-weighted total score of the questionnaire as a measure of the construct. Furthermore, measurement invariance across gender, age, and over time is supported. Finally, the Italian Intolerance of Uncertainty Scale-Revised appears to possess adequate reliability and validity. These findings support the unidimensionality of the measure, a conceptually reasonable result in line with the trans-diagnostic nature of Intolerance of Uncertainty. In addition, this study and comparison with published factor structures of the Intolerance of Uncertainty Scale-12 and of the Intolerance of Uncertainty Scale-Revised identify some issues for the internal structure of the measure. In particular, concern is expressed for the Prospective IU subscale. In light of the promising psychometric properties, the use of the Italian Intolerance of Uncertainty Scale-Revised as a univocal measure is encouraged in both research and clinical practice.
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Communication scholars have been long interested in uncertainty and its connection to communicative actions. Since the special issue of Journal of Communication on uncertainty and communication [Babrow, (2001a). Introduction to the special issue on uncertainty, evaluation, and communication. Journal of Communication, 51, 453–455. doi:10.1111/j.1460-2466.2001.tb02890.x], there is growing literature, including both theoretical advancements and empirical investigations, in this area of research, especially in health communication contexts. However, substantial variation exists in how uncertainty is defined across different research traditions, with a heavy yet narrow emphasis on probability and information deficit perspective. This paper reviews and synthesizes conceptualizations and operationalizations of uncertainty and highlights its multidimensional nature. Given that uncertainty and uncertainty management is context-specific, this paper focuses primarily on illness uncertainty. Theoretical and practical implications for understanding uncertainty and uncertainty management are discussed.
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This study meta-analyzes 32 studies that examined uncertainty's effects on anxiety and information management within a variety of illness contexts (e.g., cancer, sexually transmitted disease, heart disease). Results indicate that the direction and magnitude of uncertainty's effects vary for different information management strategies. Illness uncertainty is strongly, positively associated with anxiety and avoidance. In contrast, the average effect of uncertainty on information seeking is nonsignificant, but the association does vary depending on uncertainty conceptualization and age. Implications for understanding the nature of illness uncertainty and for communicative efforts designed to facilitate uncertainty management in illness contexts are discussed.
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The current review and synthesis serves to define and contextualize fear of the unknown relative to related constructs, such as intolerance of uncertainty, and contemporary models of emotion, attachment, and neuroticism. The contemporary models appear to share a common core in underscoring the importance of responses to unknowns. A recent surge in published research has explored the transdiagnostic impact of not knowing on anxiety and related pathologies; as such, there appears to be mounting evidence for fear of the unknown as an important core transdiagnostic construct. The result is a robust foundation for transdiagnostic theoretical and empirical explorations into fearing the unknown and intolerance of uncertainty.
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Modern anxiety disorder models implicitly include intolerance of uncertainty (IU) as a critical component for the development and maintenance of these pervasive social and economic concerns. IU represents, at its core, fear of the unknown – a long-recognized, deep-seated fear identified in normative and pathological samples. Indeed, the intrinsic nature of IU can be argued as evolutionarily supported, a notion buttressed by initial biophysiological evidence from uncertainty-related research. Originally thought to be specific to generalized anxiety disorder, recent research has clearly demonstrated that IU is a broad transdiagnostic dispositional risk factor for the development and maintenance of clinically significant anxiety. The available evidence suggests that theorists, researchers and clinicians may benefit from explicitly incorporating IU into models, research designs, case conceptualizations and as a treatment target.
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Safety-seeking behaviours are seen as playing a key role in the maintenance of various anxiety disorders. This article examines their role in panic disorder and social phobia and suggests that, whilst there are clear theoretical differences between safety-seeking behaviours and adaptive coping strategies, the difficult issue in clinical practice is being able to distinguish between the two. It builds on previous work by Salkovskis and colleagues and provides a detailed discussion of the problems in distinguishing between safety-seeking behaviours (direct avoidance, escape and subtle avoidance) and adaptive coping strategies in clinical practice. The suggestion is made that topology can only be a guide to categorizing the two types of responses and they can only be fully distinguished by taking into account the intention of the individual and their perceived function to that individual in the specific context. It is suggested that further analysis of the use of safety-seeking behaviours aimed at avoiding a variety of outcomes at differing levels of catastrophe may provide useful information that would clarify our understanding of the role of such behaviours in maintaining anxiety disorders.
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Background: Reassurance seeking is particularly prominent in obsessive-compulsive disorder (OCD) and may be important in OCD maintenance. Aims: This study used a new self-report questionnaire to measure the range of manifestations of reassurance-seeking behaviours, describing their sources from which they seek, frequency, process (how they seek), and consequences (as opposed to triggers and motivations). This study also attempts to identify the degree to which reassurance is specific to OCD as opposed to panic disorder. Method: Reassurance Seeking Questionnaire (ReSQ) was administered to 153 individuals with OCD, 50 individuals with panic disorder with/without agoraphobia, and 52 healthy controls. The reliability and validity of the measure was evaluated and found to be satisfactory. Results: Reassurance seeking was found to be more frequent in both anxiety disorders relative to healthy controls. Individuals diagnosed with OCD were found to seek reassurance more intensely and carefully, and were more likely to employ "self-reassurance" than the other two groups. Conclusions: Further investigation of reassurance will enable better understanding of its role in the maintenance of anxiety disorders in general and OCD in particular.
Article
Intolerance of uncertainty (IU) is a trait characteristic marked by distress in the face of insufficient information. Elevated IU has been implicated in the development and maintenance of anxiety disorders, particularly during adolescence, which is characterized by dramatic neural maturation and the onset of anxiety disorders. Previous task-based work implicates the bilateral anterior insula in IU. However, the association between anterior insula intrinsic functional connectivity (iFC) and IU has not been examined in adolescents. Fifty-eight healthy youth (mean age = 12.56; 55% boys) completed the Intolerance of Uncertainty Scale for Children (IUSC-12) and a 6-minute resting state fMRI scan. Group-level analyses were conducted using a random-effects, ordinary least-squares model, including IUSC-12 scores (Total, Inhibitory subscale, Prospective subscale), and three nuisance covariates (age, sex, and mean framewise displacement). IUSC-12 Inhibitory subscale scores were predictive of iFC between the left and right anterior insula and right prefrontal regions. IUSC-12 Prospective subscale scores significantly predicted iFC between the anterior insula and the anterior cingulate cortex. IUSC-12 total scores did not predict significant iFC of the bilateral anterior insula. Follow-up analyses, including anxiety (MASC Total Score) in the models, failed to find significant results. This could suggest that the associations found between IUSC-12 scores and anterior insula iFC are not unique to IU and, rather, reflect a broader anxiety-related connectivity pattern. Further studies with larger samples are needed to tease apart unique associations. These findings bear significance in contributing to the literature evaluating the neural correlates of risk factors for anxiety in youth.
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Preprint
The last decade has brought reforms to improve methodological practices, with the goal to increase the reliability and replicability of effects. However, explanations of effects remain scarce, and a growing chorus of scholars argues that the replicability crisis has distracted from a crisis of theory. In the same decade, the empirical literature using factor and network models has grown rapidly. I discuss three ways in which this literature falls short of theory building and testing. First, statistical and theoretical models are conflated, leading to invalid inferences such as the existence of psychological constructs based on factor models, or recommendations for clinical interventions based on network models. I demonstrate this inferential gap in a simulation study on statistical equivalence: excellent model fit does little to corroborate a theory, regardless of quality or quantity of data. Second, researchers fail to explicate theories about psychological constructs, but use implicit causal beliefs to guide inferences. These latent theories have led to problematic best practices in psychological research where inferences are drawn based on one specific causal model that is assumed, but not explicated. Third, explicated theories are often weak theories: narrative and imprecise descriptions vulnerable to hidden assumptions and unknowns. They fail to make clear predictions, and it remains unclear whether statistical effects corroborate such theories or not. Weak theories are immune to refutation or revision. I argue that these three challenges to theory building and testing are common and harmful, and impede theory formation, failure, and reform. A renewed focus on theoretical psychology and formal models offers a way forward.
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Intolerance of uncertainty is a dispositional trait associated with a range of psychological disorders, but the influence of methodological factors on theses associations remains unknown. The first aim of this meta-analysis was to quantify the strengths of the association between IU and symptoms of generalised anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, obsessive compulsive disorder, depression, and eating disorders. The second aim was to assess the influence of methodological factors on these relationships, including clinical (vs. non-clinical) status, age group, sex, IU measure, and symptom measure. We extracted 181 studies (N participants = 52,402) reporting 335 independent effect sizes (Pearson's r). Overall, there was a moderate association between IU and symptoms (r = 0.51, 95% CI = 0.50-0.52), although heterogeneity was high (I2 = 83.50, p < .001). Some small but significant moderator effects emerged between and within disorders. Effect sizes were not impacted by sample size. The results indicate that IU has robust, moderate associations with a range of disorder symptoms, providing definitive evidence for the transdiagnostic nature of IU.
Article
The development and conceptual relationship of the constructs of threat appraisal (TA) and intolerance of uncertainty (IU) are explored in the context of anxiety disorders. A narrative review tracking the development of these constructs and their relationship is undertaken. There is some evidence to suggest that the interaction between the components of threat appraisal (probability × cost) may partially account for or provide a theoretical framework which explains presenting levels of anxiety. Furthermore, research suggested that IU is a construct which contributes to a broad range of anxiety disorders. It was concluded that distinctive cognitive biases linked with IU – such as interpreting ambiguous and uncertain (both positive and negative) information as highly concerning – suggests that IU is interpreted negatively independent of threat appraisal. These findings mean a number of issues remain unclear, including whether IU in anxiety-provoking situations is sufficient in itself – independent of threat appraisal – in eliciting high levels of anxiety. Additionally, it is unclear whether threat appraisal and IU act as independent constructs, or more in an interactive manner in anxiety. To achieve further clarity on these issues, methodological recommendations for future research are made. Key learning aims (1) To understand the conceptual foundations of TA and IU in the cognitive model of anxiety. (2) To understand the empirical evidence supporting the role of both TA and IU in anxiety. (3) To appreciate the potential relationship between these concepts in anxiety.
Article
Recent evidence suggests that individual differences in intolerance of uncertainty (IUS) are associated with disrupted threat extinction. However, it is unknown what maintains the learned threat association in high IUS individuals: is it the experienced uncertainty during extinction or the combination of experienced uncertainty with potential threat during extinction? Here we addressed this question by running two independent experiments with uncertain auditory stimuli that varied in threat level (Experiment 1, aversive human scream (n = 30); Experiment 2, neutral tone (n = 47) and mildly aversive tone (n = 49)). During the experiments, we recorded skin conductance responses and subjective ratings to the learned cues during acquisition and extinction. In experiment 1, high IUS was associated with heightened skin conductance responding to the learned threat vs. safe cue during extinction. In experiment 2, high IUS was associated only with larger skin conductance responding to the learned cues with more threatening properties during extinction i.e. mildly aversive tone. These findings suggest that uncertainty in combination with threat, even when mild, disrupts extinction in high IUS individuals. Such findings help us understand the link between IUS and threat extinction, and its relevance to anxiety disorder pathology.
Article
People might employ unhelpful coping strategies to manage uncertainty, such as over-engagement, under-engagement, and impulsive behaviors. The current study explored the association between prospective and inhibitory intolerance of uncertainty (IU), negative urgency (NU), worry, and behavioral responses to everyday life uncertain situations. A sample comprising 130 undergraduates completed self-report measures assessing the above-mentioned constructs and general distress; among them, 69 underwent an in vivo uncertainty induction and then evaluated different strategies they might use to manage the personally relevant uncertain situation they described. In the total sample, IU dimensions, worry, and NU were positively correlated with general distress, whereas NU was not correlated with any of the IU dimensions or with worry. In participants who underwent the uncertainty induction, inhibitory IU positively predicted the use of under-engagement strategies and negatively predicted the use of over-engagement ones. Furthermore, prospective IU and worry positively predicted over-engagement behaviors. Only NU positively predicted the use of impulsive behaviors. Current findings support the differential role played by the IU dimensions in promoting the use of dysfunctional behaviors under uncertain circumstances. Furthermore, the lack of association between IU and impulsivity claims for further research considering cross-cultural issues.
Article
Uncertainty is often inevitable in everyday life and can be both stressful and exciting. Given its relevance to psychopathology and wellbeing, recent research has begun to address the brain basis of uncertainty. In the current review we examined whether there are discrete and shared neural signatures for different uncertain contexts. From the literature we identified three broad categories of uncertainty currently empirically studied using functional MRI (fMRI): basic threat and reward uncertainty, decision-making under uncertainty, and associative learning under uncertainty. We examined the neural basis of each category by using a coordinate based meta-analysis, where brain activation foci from previously published fMRI experiments were drawn together (1998–2017; 87 studies). The analyses revealed shared and discrete patterns of neural activation for uncertainty, such as the insula and amygdala, depending on the category. Such findings will have relevance for researchers attempting to conceptualise uncertainty, as well as clinical researchers examining the neural basis of uncertainty in relation to psychopathology. <br/
Article
Anxiety and anxiety disorders are associated with specific alterations to functional brain networks, including intra-networks and inter-networks. Given the heterogeneity within anxiety disorders and inconsistencies in functional network differences across studies, identifying common patterns of altered brain networks in anxiety is imperative. Here, we conducted an activation likelihood estimation meta-analysis of resting-state functional connectivity studies in anxiety and anxiety disorders (including 835 individuals with different levels of anxiety or anxiety disorders and 508 controls). Results show that anxiety can be characterized by hypo-connectivity of the affective network with executive control network (ECN) and default mode network (DMN), as well as decoupling of the ECN with the DMN. The connectivity within the salience network and its connectivity with sensorimotor network are also attenuated. These results reveal consistent dysregulations of affective and cognitive control related networks over networks related to emotion processing in anxiety and anxiety disorders. The current findings provide an empirical foundation for an integrated model of brain network alterations that are common across anxiety and anxiety disorders.
Article
Intolerance of Uncertainty is a transdiagnostic risk and maintenance factor in a range of anxiety disorders and major depressive disorder. However, the mechanism of action in the development and maintenance of anxiety disorders is poorly understood, with the relationship between the constructs of uncertainty and threat appraisal remaining unclear. Most research to date has investigated IU in situations that are explicitly or implicitly threatening (i.e. where they have a negative outcome), which makes it difficult to establish whether it is the uncertainty or the prospect of a negative outcome (or threat) that people find aversive. If the construct of IU is about uncertainty (and not threat), it should also be operating in situations where there are no negative outcomes possible. Participants (N = 224) completed a battery of online measures in tasks designed to evaluate level of situational uncertainty and perception of threat level. These tasks required responses to scenarios which displayed or implied varying levels of estimated threat. Regression analyses indicated that IU was related to perceiving threat and uncertainty in negative situations and positive situations, with the greatest contribution from uncertainty within the situations, supporting the conceptualisation of IU as a response to uncertainty that is largely independent of threat although may contribute to perceptions of threat.
Article
Intolerance of uncertainty (IU) reflects the perception of uncertainty as threatening, regardless of the true probability of threat. IU is elevated in various forms of psychopathology, uniquely associated with anxiety and depression symptoms after controlling for related constructs, and prospectively predicts symptoms. Given the ubiquity of uncertainty in daily life and the clinical implications of IU, recent work has begun to investigate the neural and psychophysiological correlates of IU. This review summarizes the existing literature and integrates findings within a mechanistic neural model of responding to uncertainty. IU is associated with heightened reactivity to uncertainty reflected in greater activity of the anterior insula and amygdala, alterations in neural responses to rewards and errors evident in event-related potentials, a mixed pattern of startle responses to uncertain threat, and deficiencies in safety learning indexed by startle and skin conductance responding. These findings provide evidence of disruptions in several domains of responding to uncertainty, threat, and reward associated with IU that may confer risk for the development of psychopathology. Significant attention is devoted to recommendations for future research, including consideration of the complex interplay of IU with emotion regulation, cognitive control, and reward processing.
Article
Mishel's uncertainty in illness theory provides a conceptual framework to explain how uncertainty is generated and how it affects psychological adjustment to the cancer experience. Since 1981, when it was created, researchers have used the theory to develop and test uncertainty management interventions in multiple populations of patients with cancer. This article reviews the theory's concepts and propositions, summarizes supporting evidence, and discusses extension of the theory, clinical implications, and future directions for research.
Article
This article describes a systematic investigation into intolerance of uncertainty (IU) behaviours. This involved systematic searches of IU behaviours, developing an expert consensus of the different types of IU behaviour and classifying behaviours into these categories.
Book
Anxiety sensitivity (AS) is the fear of anxiety sensations which arises from beliefs that these sensations have harmful somatic, social, or psychological consequences. Over the past decade, AS has attracted a great deal of attention from researchers and clinicians with more than 100 peer-reviewed journal articles published. In addition, AS has been the subject of numerous symposia, papers, and posters at professional conventions.© 1999 by Lawrence Erlbaum Associates, Inc. Why this growing interest? Theory and research suggest that AS plays an important role in the etiology and maintenance of many forms of psychopathology, including anxiety disorders, depression, chronic pain, and substance abuse. Bringing together experts from a variety of different areas, this volume offers the first comprehensive state-of-the-art review of AS--its conceptual foundations, assessment, causes, consequences, and treatment--and points new directions for future work. It will prove to be an invaluable resource for clinicians, researchers, students, and trainees in all mental health professions. © 1999 by Lawrence Erlbaum Associates, Inc. All rights reserved.
Article
Objectives: Although ambiguous and uncertain situations, such as those dealing with the threat of widespread viral illness, may have pronounced psychological ramifications, there have been few studies that examined the factors that contributed to such outcomes. The purpose of the present investigation was to examine emotional reactions to a health threat. Design: A structural equation model examined the interplay between anxiety and intolerance of uncertainty, as sequentially mediated by appraisals and coping strategies. Methods: Adult participants over the age of 18 (N = 1,027) completed online self-report measures during the H1N1 pandemic in 2009. Results: Greater intolerance of uncertainty was related to lower appraisals of self- and other control, which predicted low levels of problem-focused coping and greater reports of H1N1-related anxiety. Additionally, individuals with a high intolerance of uncertainty were more likely to perceive the pandemic as threatening and also were more apt to use emotion-focused coping strategies, and both of these factors predicted elevated levels of anxiety. Conclusions: Together, these data indicate that threats, such as those related to a potential pandemic, not only have implications for physical health, but also for psychological distress, and that such outcomes vary with a constellation of appraisal and coping factors. Statement of contribution: What is already known on this subject? It has been established that the public is often confused by the threat that a potential pandemic virus poses and that they are unsure of what information related to the disease they can trust. Government health agencies often walk the line of minimizing the threat to prevent panic, but simultaneously emphasize the importance of action (vaccination) to prevent a worldwide pandemic. What does this study add? Beyond the physical threat of a pandemic, a significant psychological toll may occur for certain individuals. Anxiety regarding H1N1 is heightened amongst those who cannot tolerate uncertainty. Appraisals of threat, control, and the use of emotion-focused coping mediate the above relationship.
Article
Discusses the conceptual bases of the state–trait distinction and suggests that the distinction, though more complex than previously appreciated, is conceptually viable. B. P. Allen and C. R. Potkay's (see record 1982-09834-001) contention that the state–trait distinction is arbitrary is rejected. Rather than attempting to reduce the state–trait distinction to a single dimension, the author proposes 4 overlapping but distinct dimensions as underlying current professional uses of the distinction: duration, continuous vs reactive manifestation, concreteness vs abstractness, and situational causality vs personal causality. Parallels are drawn between these dimensions and aspects of the broader concepts of occurrence and disposition, and the concepts of state and trait are described as applications in psychology of these broader concepts. It is argued that a clearer understanding of the concepts of state and trait will facilitate theory and research. (42 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The theoretical and empirical basis of commonly accepted propositions concerning the role of behaviour in the practice of behavioural psychotherapy for anxiety problems is considered. A number of problems are identified, and an alternative, more explicitly cognitive hypothesis is described. According to this cognitive account, there is both a close relationship and specific interactions between “threat cognitions” and “safety seeking behaviour”. For any individual, safety seeking behaviour arises out of, and is logically linked to, the perception of serious threat. Such behaviour may be anticipatory (avoidant) or consequent (escape). Because safety seeking behaviour is perceived to be preventative, and focused on especially negative consequences (e.g. death, illness, humiliation), spontaneous disconfirmation of threat is made particularly unlikely by such safety seeking behaviours. By preventing disconfirmation of threat-related cognitions, safety seeking behaviour may be a crucial factor in the maintenance of anxiety disorders. The implications of this view for the understanding and treatment of anxiety disorders are discussed.
Article
This article reviews the main issues associated with the concept and the diagnosis of generalized anxiety disorder (GAD) and examines the proposed DSM-5 diagnostic criteria for GAD. The lack of specific features, which is the primary issue for GAD, will not be addressed in DSM-5. The hallmark of the condition will remain pathological worry, although it also characterizes other disorders. Likewise, the proposed behavioral diagnostic criteria lack specificity for GAD, and it is not clear how these will be assessed. The proposed changes will lower the diagnostic threshold for GAD in DSM-5. Although this will not necessarily lead to a better recognition of GAD and an improvement in the perception of its relevance and clinical utility, many currently subthreshold cases will qualify for this diagnosis. The likely inclusion of many such "false-positives" will result in an artificial increase in the prevalence of GAD and will have further negative consequences.
Article
A cognitive model of panic is described. Within this model panic attacks are said to result from the catastrophic misinterpretation of certain bodily sensations. The sensations which are misinterpreted are mainly those involved in normal anxiety responses (e.g. palpitations, breathlessness, dizziness etc.) but also include some other sensations. The catastrophic misinterpretation involves perceiving these sensations as much more dangerous than they really are (e.g. perceiving palpitations as evidence of an impending heart attack). A review of the literature indicates that the proposed model is consistent with the major features of panic. In particular, it is consistent with the nature of the cognitive disturbance in panic patients, the perceived sequence of events in an attack, the occurrence of ‘spontaneous’ attacks, the role of hyperventilation in attacks, the effects of sodium lactate and the literature on psychological and pharmacological treatments. Finally, a series of direct tests of the model are proposed.
Article
Over the last few years there has been increased interest in worry. Most assessment up until now has been concerned with what people worry about and how much they worry rather than exploring reasons for worrying. Two questionnaires were developed to go beyond the content and intensity of worry. The first questionnaire, Why Worry?, contains 20 items and assesses reasons why people say they worry. Two types of reasons were found. First, subjects believe that worrying can prevent negative outcomes from happening, minimize the effects of negative events by decreasing guilt, avoiding disappointment, or provide distraction from thinking about things that are even worse. Second, people believe worrying has positive effects such as finding a better way of doing things, increasing control, and finding solutions. The second questionnaire, Intolerance of Uncertainty, consists of 27 items that assesses emotional, cognitive and behavioral reactions to ambiguous situations, implications of being uncertain, and attempts to control the future. The second study demonstrates the instruments' properties by distinguishing between levels of worry, by factor analysis describing the dimensions underlying the constructs, and by establishing appropriate relationships with measures of worry and emotional distress. The implications for current models of worry are discussed.
Article
Intolerance of uncertainty (IU) - a dispositional characteristic resulting from negative beliefs about uncertainty and its implications - may be an important construct in anxiety disorders and depression. Despite the potential importance of IU, clinical data on the construct remains relatively scant and focused on generalized anxiety disorder and obsessive-compulsive disorder. The present study systematically investigated IU, as measured by the Intolerance of Uncertainty Scale-12 (IUS-12), across groups diagnosed with anxiety disorders (i.e., social anxiety disorder, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder) or depression (clinical sample: n=376; 61% women), as well as undergraduate (n=428; 76% women) and community samples (n=571; 67% women). Analysis of variance revealed only one statistically significant difference in IUS-12 scores across diagnostic groups in the clinical sample; specifically, people with social anxiety disorder reported higher scores (p<.01; η(2)=.03) than people with panic disorder. People diagnosed with an anxiety disorder or depression reported significantly and substantially higher IUS-12 scores relative to community and undergraduate samples. Furthermore, IUS-12 score distributions were similar across diagnostic groups as demonstrated by Kernel density estimations, with the exception of panic disorder, which may have a relatively flat distribution of IU. Response patterns were invariant across diagnostic groups as demonstrated by multi-group confirmatory factor analyses, but varied between clinical and nonclinical samples. Overall, the findings suggest IU may serve as an important transdiagnostic feature across anxiety disorders and depression. In addition, robust support was found for the proposed 2-factor model of the IUS-12. Comprehensive findings, implications, and future research directions are discussed.
Article
Since its emergence in the early 1990s, a narrow but concentrated body of research has developed examining the role of intolerance of uncertainty (IU) in worry, and yet we still know little about its phenomenology. In an attempt to clarify our understanding of this construct, this paper traces the way in which our understanding and definition of IU have evolved throughout the literature. This paper also aims to further our understanding of IU by exploring the latent variables measures by the Intolerance of Uncertainty Scale (IUS; Freeston, Rheaume, Letarte, Dugas & Ladouceur, 1994). A review of the literature surrounding IU confirmed that the current definitions are categorical and lack specificity. A critical review of existing factor analytic studies was carried out in order to determine the underlying factors measured by the IUS. Systematic searches yielded 9 papers for review. Two factors with 12 consistent items emerged throughout the exploratory studies, and the stability of models containing these two factors was demonstrated in subsequent confirmatory studies. It is proposed that these factors represent (i) desire for predictability and an active engagement in seeking certainty, and (ii) paralysis of cognition and action in the face of uncertainty. It is suggested that these factors may represent approach and avoidance responses to uncertainty. Further research is required to confirm the construct validity of these factors and to determine the stability of this structure within clinical samples.
Article
Evidence is accumulating that intolerance of uncertainty (IU) may be a transdiagnostic maintaining factor across the anxiety disorders and depression. However, psychometric studies of the most commonly used measure of IU have typically used undergraduate students, and the factor structure has been highly inconsistent. Previous studies have also tended to focus on one diagnostic subgroup or related symptom, thereby limiting transdiagnostic comparisons. The first aim of this study was to test the latent structure of a commonly used measure of IU in a treatment-seeking sample with anxiety and depression (n=463). The second aim was to examine psychometric properties of the best fitting solution, including internal reliability, convergent validity, and discriminant validity. Confirmatory factor analysis was used to compare the goodness of fit of five models previously found with undergraduate and community samples. A two-factor solution, comprising of prospective anxiety and inhibitory anxiety, was the best fitting model. The total scale and subscales demonstrated excellent internal reliability. Convergent validity was demonstrated by the scales correlating with symptoms associated with five anxiety disorders and depression, as well as neuroticism, distress and disability. IU explained unique variance in all symptom measures, even after controlling for neuroticism and other symptom measures. Evidence of discriminant validity was also found for each IU subscale. Findings support reliability and validity of the two-factor solution, and are consistent with IU being a transdiagnostic maintaining factor.
Article
Options for revising the DSM-IV Generalized Anxiety Disorder (GAD) diagnostic criteria have been made by the DSM-5 Anxiety, Obsessive-Compulsive, Post-traumatic and Dissociative Disorders Work Group. It has been proposed that renaming the disorder Generalized Worry Disorder, clarifying criterion A to emphasize the primacy of worry, reducing the duration required, altering the list of associated symptoms to reflect the concomitants of worry that are specific to GAD, and adding behavioural criteria could clarify the concept of chronic worry for clinicians and enhance the reliability of the diagnosis. The influence of the proposed changes on the prevalence and severity of cases is examined. Data from a national survey and from a clinical data set were used to quantify the effect of the proposed changes. Reducing the duration from 6 to 3 months and removing the clinical significance criterion raised the prevalence of GAD, whereas revising the associated symptoms and adding behavioural symptoms reduced the prevalence. With all the new options implemented, although the prevalence of the diagnosis rose by 9%, it was associated with similar levels of distress and impairment as DSM-IV cases. There is preliminary evidence that the proposals may increase the prevalence of GAD but may not influence the severity of cases. The clinical utility, reliability and validity of the diagnosis remains to be established.
Article
Generalized anxiety disorder (GAD) has undergone a series of substantial classificatory changes since its first inclusion in DSM-III. The majority of these revisions have been in response to its poor inter-rater reliability and concerns that it may lack diagnostic validity. This article provides options for the revision of the DSM-IV GAD criteria for DSM-V. First, searches were conducted to identify the evidence that previous DSM Work Groups relied upon when revising the DSM-III-R GAD and the overanxious disorder classifications. Second, the literature pertaining to the DSM-IV criteria for GAD was examined. The review presents a number of options to be considered for DSM-V. One option is for GAD to be re-labeled in DSM-V as generalized worry disorder. This would reflect its hallmark feature. Proposed revisions would result in a disorder that is characterized by excessive anxiety and worry generalized to a number of events or activities for 3 months or more. Worry acts as a cognitive coping strategy that manifests in avoidant behaviors. The reliability and validity of the proposed changes could be investigated in DSM-V validity tests and field trials.
Article
There has been significant interest in the role of anxiety sensitivity (AS) in the anxiety disorders. In this meta-analysis, we empirically evaluate differences in AS between anxiety disorders, mood disorders, and nonclinical controls. A total of 38 published studies (N = 20,146) were included in the analysis. The results yielded a large effect size indicating greater AS among anxiety disorder patients versus nonclinical controls (d = 1.61). However, this effect was maintained only for panic disorder patients compared to mood disorder patients (d = 0.85). Panic disorder was also associated with greater AS compared to other anxiety disorders except for posttraumatic stress disorder (d = 0.04). Otherwise the anxiety disorders generally did not differ from each other in AS. Although these findings suggest that AS is central to the phenomenology of panic disorder and posttraumatic stress disorder, causal inferences regarding the role of AS in these anxiety disorders cannot be made. Moderator analyses showed that a greater proportion of female participants was associated with larger differences in AS between anxiety and nonclinical control groups. However, more female participants were associated with a smaller AS difference between anxiety and mood disorder groups. This finding suggests that AS is less robust in distinguishing anxiety from mood disorders among women. Age also moderated some observed effects such that AS was more strongly associated with anxiety disorders in adults compared to children. Type of AS measure used also moderated some effects. Implications of these findings for the conceptualization of AS in anxiety-related disorders are discussed.
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This study examined the factor structure of the English version of the Intolerance of Uncertainty Scale (IUS; French version: M. H. Freeston, J. Rhéaume, H. Letarte, M. J. Dugas, & R. Ladouceur, 1994; English version: K. Buhr & M. J. Dugas, 2002) using a substantially larger sample than has been used in previous studies. Nonclinical undergraduate students and adults from the community (M age = 23.74 years, SD = 6.36; 73.0% female and 27.0% male) who participated in 16 studies in the Anxiety Disorders Laboratory at Concordia University in Montreal, Canada were randomly assigned to 2 datasets. Exploratory factor analysis with the 1st sample (n = 1,230) identified 2 factors: the beliefs that "uncertainty has negative behavioral and self-referent implications" and that "uncertainty is unfair and spoils everything." This 2-factor structure provided a good fit to the data (Bentler-Bonett normed fit index = .96, comparative fit index = .97, standardized root-mean residual = .05, root-mean-square error of approximation = .07) upon confirmatory factor analysis with the 2nd sample (n = 1,221). Both factors showed similarly high correlations with pathological worry, and Factor 1 showed stronger correlations with generalized anxiety disorder analogue status, trait anxiety, somatic anxiety, and depressive symptomatology.
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The middle-range nursing theory of uncertainty in illness is presented from both a theoretical and empirical perspective. The theory explains how persons construct meaning for illness events, with uncertainty indicating the absence of meaning. A model of the uncertainty theory displaying the concepts and their relationships forms the basis for the theoretical and empirical material. Discussion of the theory is organized around three major themes: the antecedents of uncertainty, the process of uncertainty appraisal and coping with uncertainty.
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Cognitive-behavioural approaches have made no impact on research and treatment in obsessional-compulsive disorder, despite the obvious link between thinking and psychopathology that characterizes this disorder. A close examination of cognitive and behavioural models leads to the suggestion that intrusive thoughts are best regarded as cognitive stimuli rather than responses. Cognitive responses (negative automatic thoughts) to these stimuli are typically linked to beliefs concerning responsibility or blame for harm to self or others. A cognitive-behavioural model based on this view is outlined and illustrated by clinical material derived from a case series. The model is used to explain a wide range of phenomena observed clinically, and a number of specific predictions are made. Implications for cognitive approaches to therapy are discussed.
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Examines the literature relating to obsessions and compulsions from the early identification of the syndrome to contemporary theorizing. The essential characteristic of compulsion is subjective resistance and stereotypy alone is insufficient to delineate the disorder. There is a distinction to be made between symptoms and traits, and the use of the term obsessional personality to describe a careful, thorough, and punctual person is misleading. Compulsive disorders (both cognitive and motor) are dependent on anxiety in the acute stages, and overt symptoms (whether active or passive) serve to reduce anxiety. Existing learning theory models are inadequate, but recent approaches using decision theory concepts are more promising and can incorporate those instances in which conditioning principles apply as special cases. (53 ref)
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Summary~The addition of a 'safety perspective' to the construal of agoraphobia as avoidance behaviour is proposed as a means of addressing several theoretical problems. Regarding agoraphobia as a balance between danger and safety signals enables one to re-examine the problem of the undue persistence of the avoidance behaviour component. It also opens for consideration the 'non-exposure' onset of agoraphobia (e.g. after loss or bereavements), the age of onset, the sex ratio, the role of trusted companions and talismen. A method for studying safety signals and safety factors is adumbrated. and some predictions are made. The advantages and limitations of the 'safety perspective' are considered. The purpose of the present paper is to develop a fresh perspective on agoraphobia, using as a starting point the common clinical observation that much of the behaviour associated with agoraphobia can be construed as an attempt to achieve and maintain a sense of safety. It will be argued that adopting a 'safety perspective' enables one to make more intelligible a number of insufficiently understood manifestations of agoraphobia, and that furthermore, this new perspective can be put to productive use in the planning of research and ultimately in the development of new forms of management. The potential therapeutic application of the 'safety perspective' has been