Resolving Uncertainty About the Role of Uncertainty Intolerance as a Contributing Factor to Obsessive-Compulsive Disorder and Related Disorders

Full text

COMMENTARY
Resolving Uncertainty About the Role of Uncertainty Intolerance as a
Contributing Factor to Obsessive-Compulsive Disorder and Related Disorders
Michael G. Wheaton
Department of Psychology, Barnard College, New York, New York, United States
Obsessive–compulsive disorder (OCD) tends to run a chronic
course when not adequately treated and causes substantial
functional impairment for sufferers (American Psychiatric
Association [APA], 2013). The significant illness burden associ-
ated with OCD necessitates research on the factors that contrib-
ute to the development and maintenance of OCD symptoms.
One candidate contributing factor to OCD is intolerance of
uncertainty (IU), which has been defined as the “dispositional
incapacity to endure the aversive response triggered by the per-
ceived absence of salient, key, or sufficient information, and sus-
tained by the associated perception of uncertainty”(Carleton,
2016, p. 31). In their article, Knowles and Olatunji (2023) pro-
vide a comprehensive review and critical appraisal of the
research literature linking IU to OCD. Their article provides
key criteria for evaluating the evidence supporting IU as a cog-
nitive vulnerability for OCD. Importantly, their review shows
that some criteria (e.g., robust associations between IU and
OCD symptoms) have extensive empirical support, whereas oth-
ers (e.g., temporal precedence of change in IU preceding change
in OCD symptoms) are characterized by mixed findings. Overall,
given the historical nature of the association between OCD and
IU and the centrality of learning to live with doubt in OCD
treatments (Grayson, 2010), it is perhaps somewhat surprising
how many ambiguities and unknowns remain in the empirical
literature on the relationship between IU and OCD. Knowles
and Olatunji (2023) identify the relevant gaps in the literature
and offer important directions for future research. Their review
has substantial merit to improve the science while also acknowl-
edging the barriers and challenges future research will face. This
commentary provides support for these recommendations and
also highlights additional areas for consideration for future
research on IU.
Consideration of Sensitivity and Specificity in the
Relationship Between IU and OCD
Sensitivity and specificity, concepts often used in relation to diag-
nostic testing, also have relevance for the connections between can-
didate risk factors (i.e., elevated IU) and outcomes (i.e.,
development of OCD). Specificity relates to whether the vulnerabil-
ity factor of elevated IU is specific to OCD, as compared to other
conditions. Given that IU is considered to be a transdiagnostic con-
tributing factor, having been linked to a wide range of emotional dis-
orders, including anxiety disorders (notably generalized anxiety
disorder; GAD), and depression (Rosser, 2019), the specificity of
the association between IU and OCD appears to be relatively low.
Of course, this does not negate the importance of considering IU
as a contributing factor to OCD, though it does raise important ques-
tions for consideration. For example, given the difference in relative
prevalence rates (OCD is experienced by approximately 1%–2% of
the population, whereas depression and GAD have prevalence rates
multiple times higher than OCD; APA, 2013), it seems plausible that
the majority of individuals experiencing the cognitive vulnerability
factor of elevated IU may actually develop a disorder other than
OCD. The additional variables involved in determining why some
individuals with heightened IU develop OCD instead of another
condition such as GAD, warrant additional attention, particularly
as pertains to risk factors that may be specific to OCD. Elevated
IU might act in concert with other contributing factors for the devel-
opment of OCD, including variables such as obsessive beliefs, dis-
gust sensitivity, distress intolerance, and anxiety sensitivity. Future
models might consider interactions among risk these variables as
additive risk factors for OCD.
On the other hand, sensitivity would refer to the proportion of
individuals experiencing OCD who also demonstrate the vulnerabil-
ity factor of heightened IU. As Knowles and Olatunji (2023) review,
the existing literature finds that IU is more strongly linked to some
presentations of OCD than others. Drawing on the notion of equifin-
ality (the notion that multiple different pathways may lead to a given
end-state), some models have suggested that there are multiple path-
ways and constellations of contributing factors that could lead to the
development of OCD (Kalanthroff & Wheaton, 2022). Whereas
heightened IU may be a contributing factor for some individuals
with OCD, the existing data leaves open the possibility that not all
OCD patients have trouble tolerating uncertainty. Importantly,
OCD is frequently noted for its heterogeneity in terms of age of
onset, symptom dimension, and treatment response. Empirical
study could help to establish whether individual differences in IU
Michael G. Wheaton https://orcid.org/0000-0002-7465-7879
This work did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors. The author declares that he has
no conflict of interest.
Michael Wheaton served as lead for conceptualization, writing–original
draft, and writing–review and editing.
Correspondence concerning this article should be addressed to Michael
G. Wheaton, Department of Psychology, Barnard College, 3009 Broadway,
New York, NY 10027, United States. Email: mwheaton@barnard.edu
Clinical Psychology: Science and Practice
© 2023 American Psychological Association 2023, Vol. 30, No. 3, 334–336
ISSN: 0969-5893 https://doi.org/10.1037/cps0000157
334
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.