Professional Documents
Culture Documents
com
www.elsevier.com/locate/bt
To Be Sure, To Be Sure: Intolerance of Uncertainty Mediates Symptoms of Various Anxiety Disorders and Depression
Peter M. McEvoy Centre for Clinical Interventions, Perth University of Western Australia, Perth Alison E.J. Mahoney Clinical Research Unit for Anxiety and Depression, Sydney
were associated with significant indirect effects, although the mediation effect was stronger for worry than other symptoms. Potential implications of these findings for the treatment of anxiety disorders and depression are discussed.
The Intolerance of Uncertainty Model was initially developed as an explanation for worry within the context of generalized anxiety disorder. However, recent research has identified intolerance of uncertainty (IU) as a possible transdiagnostic maintaining factor across the anxiety disorders and depression. The aim of this study was to determine whether IU mediated the relationship between neuroticism and symptoms related to various anxiety disorders and depression in a treatment-seeking sample (N = 328). Consistent with previous research, IU was significantly associated with neuroticism as well as with symptoms of social phobia, panic disorder and agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, and depression. Moreover, IU explained unique variance in these symptom measures when controlling for neuroticism. Mediational analyses showed that IU was a significant partial mediator between neuroticism and all symptom measures, even when controlling for symptoms of other disorders. More specifically, anxiety in anticipation of future uncertainty (prospective anxiety) partially mediated the relationship between neuroticism and symptoms of generalized anxiety disorder (i.e. worry) and obsessive-compulsive disorder, whereas inaction in the face of uncertainty (inhibitory anxiety) partially mediated the relationship between neuroticism and symptoms of social anxiety, panic disorder and agoraphobia, and depression. Sobel's test demonstrated that all hypothesized meditational pathways
Address correspondence to Peter M. McEvoy, Ph.D., Centre for Clinical Interventions, 223 James Street, Northbridge, Perth, Western Australia, 6003; e-mail: peter.mcevoy@health.wa.gov.au.
0005-7894/43/533-545/$1.00/0 2011 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
INTOLERANCE OF UNCERTAINTY (IU) has been broadly defined as cognitive, emotional, and behavioral reactions to uncertainty that bias information processing and lead to faulty appraisals of heightened threat and reduced coping (Freeston, Rhaume, Letarte, Dugas, & Ladouceur, 1994). The Intolerance of Uncertainty Model (IUM) was initially developed with reference to generalized anxiety disorder (GAD; Dugas, Letarte, Rhaume, Freeston & Ladouceur, 1995; Freeston et al., 1994), which is characterized by excessive and uncontrollable worry (American Psychiatric Association, 1994). More recently, however, it has been argued that IU might be a transdiagnostic mechanism that contributes to the maintenance of symptoms across anxiety disorders and depression (e.g., Boelen & Reijntjes, 2009; McEvoy & Mahoney, 2011). If IU is demonstrated to be related to multiple internalizing disorders, this would have important implications for the development of innovative transdiagnostic treatment protocols. The IUM suggests that individuals with GAD find uncertainty distressing, which leads to the commencement of worrying when confronted with an uncertain or ambiguous situation (e.g., What if [something bad]
534
happens?). The extent to which these individuals believe that worrying can be helpful (e.g., worrying will help to prevent bad things from happening) will then determine whether they are motivated to continue engaging in worrisome thoughts, which, in turn, leads to anxiety. The IUM outlines two feedback loops. The first suggests that anxiety leads to a negative problem orientation, which is associated with the belief that problems are threatening as well as low problem-solving confidence, which increases the intensity of worry. The second feedback loop suggests that anxiety also leads to cognitive avoidance, whereby the individual is motivated to engage in unhelpful strategies such as thought suppression, distraction, and thought replacement. In the short term these strategies might be negatively reinforced by a reduction in worrisome thoughts and anxiety. However, they also prevent underlying threat appraisals from being modified, which ultimately results in more worrisome thoughts, thereby completing the cycle. The model acknowledges the impact of life stressors and mood state, and the end point is exhaustion and demoralization (Behar, DiMarco, Hekler, Mohlman, & Staples, 2009). There is considerable evidence that IU is a cognitive vulnerability factor for worry (Koerner & Dugas, 2008; Ladouceur, Gosselin, & Dugas, 2000; Sexton, Norton, Walker, & Norton, 2003; van der Heiden et al., 2010) and may be an important maintaining factor for GAD (Behar et al., 2009; Dugas, Gagnon, Ladouceur, & Freeston, 1998). IU is consistently associated with worry (e.g., Berenbaum, Bredemeier, & Thompson, 2008) and has been found to be a more robust predictor than several other proposed maintaining factors, including positive metabeliefs, negative problem orientation, cognitive avoidance, perfectionism, perceived control, and intolerance of ambiguity (Buhr & Dugas, 2006; Laugesen, Dugas, & Bukowski, 2003). Experimental studies have also found reliable associations between IU and worry (Buhr & Dugas, 2009; Ladouceur, Talbot, & Dugas, 1997; Ladouceur et al., 2000; Rosen & Knuper, 2009). IU has been found to distinguish between nonclinical worriers and those with GAD of varying severity (Dugas et al., 2007; Ladouceur, Blais, Freeston, & Dugas, 1998), and van der Heiden et al. (2010) found that the relationship between neuroticism and symptoms of GAD was mediated by both IU and negative metacognitions in a clinical sample with primary GAD. Finally, changes in IU are associated with improvements in worry and anxiety symptoms during cognitivebehavioral therapy (CBT; Dugas & Ladouceur, 2000; Dugas et al., 2003). Dugas et al. (2010) compared CBT targeting IU to applied relaxation
535
been variable. In an undergraduate sample, Dugas, Schwartz, and Francis (2004) found that while IU was more strongly associated with worry than depression, both worry and depression explained unique variance in IU. In an analog sample with varying degrees of somatic and cognitive GAD symptoms, Buhr and Dugas (2002) found that IU was not more strongly associated with worry than depression or anxiety symptoms. Interestingly, de Jong-Meyer, Beck, and Riede (2009) found that in a community sample IU was more strongly correlated with depression than anxiety symptoms, and that IU continued to be significantly associated with depression when controlling for metacognitive beliefs. In a dysphoric sample included in the same study, however, although IU was significantly correlated with depression symptoms, it did not explain unique variance above and beyond metacognitive beliefs. Importantly, van der Heiden et al. (2010) found that the relationship between neuroticism and depression symptoms was mediated by both IU and negative metacognitions in a clinical sample. Thus, IU appears to be associated with depression symptoms, although the strength of this association relative to other symptoms and cognitive constructs has varied across studies. In sum, IU appears to be associated with a broad array of anxiety and depressive disorders and thus may represent an important transdiagnostic maintaining factor (Starcevic & Berle, 2006). However, there are several limitations of existing studies. First, most studies have used nonclinical samples, bringing into question the generalizability of the findings to treatment-seeking individuals with various anxiety and depressive disorders. Second, some studies focus on the relative strength of endorsement of IU across diagnostic or analog groups (i.e., compare group means), rather than examining the relative contribution of IU to symptoms across disorder-related symptoms or testing meditational models. Although individuals with GAD might endorse measures of IU more strongly than other disorder groups, IU may nonetheless be an important contributor to symptoms of other disorders. Third, many studies have examined IU within the context of a single diagnostic group or with diagnosis-specific symptom measures, which precludes examination of IU as a transdiagnostic process. This study sought to address these limitations by using a large mixed-diagnosis clinical sample to test whether IU mediates the relationship between neuroticism and symptoms of GAD, PD/A, social phobia, OCD, and depression. Moreover, recent research has suggested that different aspects of IU are associated with symptoms of different anxiety and depressive disorders, so this study also sought to examine
536
whether these differences extended to mediation effects between neuroticism and symptoms. Specifically, Carleton, Norton, and Asmundson (2007) found that a 12-item version of the IUS (Freeston et al., 1994) provided the best fit to the data from two undergraduate samples, and that the total score correlated with worry, symptoms of GAD, depression, and anxiety. This version of the IUS is comprised of two subscales, namely, prospective anxiety (IUS-PA) and inhibitory anxiety (IUS-IA). Prospective anxiety relates to fear and anxiety in anticipation of uncertainty, whereas inhibitory anxiety relates to inaction in the face of uncertainty. A recent study with a treatment-seeking sample found that the IUS was significantly associated with diagnosis-related symptoms for PD/A, social phobia, OCD, GAD, and depression, even when controlling for all other symptom measures and neuroticism (McEvoy & Mahoney, 2011). Moreover, the IUS-PA was uniquely associated with symptoms of GAD and OCD, whereas the IUS-IA was uniquely associated with symptoms relating to the phobic disorders (social phobia, PD/A) and depression. The only other study using this version of the IUS in a clinical sample also found that inhibitory anxiety, but not prospective anxiety, was uniquely associated with social anxiety symptoms (Carleton et al., 2010). Together, these findings suggest that individuals with GAD and OCD particularly fear future uncertainty, which is consistent with the fact that worry and obsessions are often future oriented (i.e., anticipatory). In contrast, those with phobic disorders and depression are more paralyzed in the face of uncertainty, which is consistent with the fact that phobic disorders and depression are associated with inaction and withdrawal (i.e., inhibition). Thus, IU was found to be a transdiagnostic phenomenon, although different aspects of IU were related to different symptoms of internalizing disorders. This study sought to extend these findings by testing whether IU mediates the relationship between the general vulnerability factor of neuroticism and symptoms of various anxiety disorders and depression. Guided by the findings of McEvoy and Mahoney (2011) and Carleton et al. (2010), it was hypothesized that the IUS-PA would mediate the relationship between neuroticism and symptoms of GAD and OCD. It was further expected that the IUS-IA would mediate the relationship between neuroticism and symptoms of social anxiety, PD/A, and depression.
Method
participants Participants (N = 328, 54% women) were referred to a specialist anxiety disorders treatment service by
measures Composite International Diagnostic InterviewAuto The CIDI-Auto was used to assess the presence of anxiety and depressive disorders in the current sample. The CIDI-Auto is a computerized, selfreported, structured diagnostic interview for mental disorders according to International Classification of Diseases (ICD-10; World Health Organization, 1993) and the DSM-IV (American Psychiatric Association, 1994). It has demonstrated procedural validity against expert clinical diagnoses (Peters & Andrews, 1995) and has good reliability (Andrews & Peters, 1998; Wittchen, 1994).
537
and testretest reliability (r = .93 over 1 week) are established (Beck et al., 1996), and evidence for construct validity has been demonstrated (e.g., Dozois, Dobson, & Ahnberg, 1998; Osman, Kopper, Barrios, Gutierrez, & Bagge, 2004). Social Phobia Scale and Social Interaction Anxiety Scale The Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998) are widely used, 20-item measures of performance and interaction anxiety, respectively. The SPS describes situations in which the person is the focus of attention and observed by others, such as eating, drinking, and writing. The SIAS contains items reflecting cognitive, affective, and behavioral reactions to interactional situations, such as nervousness when speaking to authority, mixing with people, and talking to an attractive person of the opposite sex. The 5-point response scale for both scales is not at all, slightly, moderately, very, or extremely characteristic of me. Internal reliabilities for the SPS ( = .89) and SIAS ( = .93) are high within clinical samples and these scales have been shown to be sensitive to change (Cox, Ross, Swinson, & Direnfeld, 1998; Mattick, Peters, & Clarke, 1989). Eysenck Personality QuestionnaireNeuroticism Subscale The 23-item neuroticism subscale of the Eysenck Personality Questionnaire (EPQ-N; Eysenck & Eysenck, 1975) was used in the current study. Data demonstrating reliability and validity of the EPQ-N are extensive (e.g., see Barrett, Petrides, Eysenck, & Eysenck, 1998; Caruso, Witkiewitz, Belcourt-Dittloff, & Gottlieb, 2001). Padua InventoryWashington State University Revision The Padua InventoryWashington State University Revision (PI; Burns, 1995) is a widely used 39-item self-report measure of OCD symptoms. Each item (e.g., I feel my hands are dirty when I touch money) is rated on a 5-point scale according to the degree of disturbance caused by the thought or behavior from 0 (not at all) to 4 (very much). Although subscale scores are available, the total score was used in the current study. Evidence of construct, convergent, and discriminant validity has been demonstrated (Burns, Keortge, Formea, & Sternberger, 1996; Jnsdttir & Smri, 2000).
procedure Patients referred to a specialist anxiety disorders clinic completed a standard battery of questionnaires during their initial assessment, including the
538
IUS, PSWQ, BSQ, ACQ, PI, SPS, SIAS, BDI-II, and EPQ-N. Data were available for 328 patients. In addition, a subsample completed the CIDI-Auto as a structured diagnostic assessment of anxiety and affective disorders (n = 106). All patients consented for their data to be used for research purposes and the use of the data was approved by the hospital's Human Research Ethics Committee.
Means, Standard Deviations and Cronbach's Alphas for Symptom Measures, Neuroticism, and Intolerance of Uncertainty
Measure Mean SD
Results
data screening Prior to data analyses, distributions, skewness, and kurtosis were examined for scale total scores (ACQ, BSQ, BDI-II, EPQ-N, PSWQ, SIAS, SPS, PI, IUS-PA, IUS-IA). Scores were generally normally distributed with most items demonstrating acceptable levels of skewness and kurtosis (b |1.00|). One exception to this was the PI total score, with a skew of 1.33 and kurtosis of 1.57. A square-root transformation reduced these values to .51 and .25, respectively. All subsequent analyses were conducted with this transformed variable (PIsqrt). Total scores were then screened for univariate and multivariate outliers. Eight participants were removed because they had standardized total scores greater than 3 on at least one variable, suggesting that they were univariate outliers. Mahalanobis Distance with a chi-square cutoff of 29.59 (10 variables, p = .001) indicated one multivariate outlier, which was removed. Thus, the final total was 319 participants, who were used for all subsequent analyses.
Scale Descriptive Statistics and Internal Consistency Means, standard deviations, and internal reliability estimates (Cronbach's ) for symptom measures, neuroticism, and IUS subscales are reported in Table 1. The means place the sample in the clinical range on the SPS and SIAS (Mattick & Clarke, 1998), PSWQ (Brown et al., 1992; Gillis, Haaga, & Ford, 1995), and BSQ and ACQ (Chambless et al., 1984; Chambless & Gracely, 1989). While the total sample mean on the PI fell within the nonclinical range, the mean score for participants with a CIDIAuto diagnosis of OCD ( n = 19, M = 57.37, SD = 24.54) fell within the clinical range (Burns et al., 1996). Mean score on the BDI-II placed the sample in the moderate range for depression. Therefore, on average, the current sample experienced symptoms in the clinical range. The alphas range from good to excellent.
21.87 15.53 17.98 42.54 28.76 63.92 42.12 31.82 27.48 23.25
6.73 5.04 3.46 15.30 9.77 11.43 18.69 19.03 22.63 12.38
.87 .86 .79 .93 .85 .74 .90 .94 .94 .93
Note. BSQ = Bodily Sensation Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SIAS = Social Interaction Anxiety Scale, SPS = Social Phobia Scale, PI = Padua Inventory (untransformed), BDI-II = Beck Depression Inventory-II, EPQ-N = Eysenck Personality Questionnaire Neuroticism subscale, IUS-PA = Intolerance of Uncertainty Scale Prospective Anxiety subscale, IUS-IA = Intolerance of Uncertainty Scale Inhibitory Anxiety subscale.
test of mediation effects Composite scores were created for social anxiety (SPS + SIAS/2) and PD/A (BSQ + ACQ/2) prior to analysis, because these measures were considered to measure different aspects of the same disorder groups studied
here (social phobia and panic disorder with or without agoraphobia, respectively). The SPS and SIAS were correlated at .72 and the composite score was correlated at .93 with both measures, suggesting that the composite score reflected scores on both measures. Likewise, the BSQ and ACQ were correlated at .71 and the composite score correlated at .96 with the BSQ and .89 with the ACQ, suggesting that the composite score reflected scores on both measures. The IUS-PA and the IUS-IA were significantly associated with neuroticism, as well as all symptom scores (all ps b .001; see Table 2). Previous research with an almost identical sample to the one used in this study found that IUS-PA was uniquely associated with PSWQ and PI, whereas IUS-IA was uniquely associated with SPS/SIAS composite, BSQ/ACQ composite, and BDI-II (McEvoy & Mahoney, 2011). We reran these analyses with this sample and found an identical pattern of results so they are not reported again here. Therefore, in this study it was expected that PI would mediate the relationship between neuroticism and PSWQ and PIsqrt, whereas IUS-IA would mediate the relationship between neuroticism and ACQ/BSQ, SPS/SIAS, and BDI-II. A series of linear regression analyses were conducted to determine whether the four conditions needed to establish mediation were met (Baron & Kenny, 1986). Dependent variables were the symptom measures. The first condition to establish mediation is that the independent variable (neuroticism) is significantly related to the dependent variables (symptom measures). This condition was
539
Pearson Bivariate Correlation Coefficients Between Intolerance of Uncertainty Subscales, Neuroticism, and Symptom Measures
Symptom Measure IUS-PA IUS-IA EPQ-N BSQ/ACQ PSWQ SIAS/SPS PIsqrt
.32* .40*
.37*
Note. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SIAS = Social Interaction Anxiety Scale, SPS = Social Phobia Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression Inventory-II, EPQ-N = Eysenck Personality Questionnaire Neuroticism subscale, IUS-PA = Intolerance of Uncertainty Scale Prospective Anxiety subscale, IUS-IA = Intolerance of Uncertainty Scale Inhibitory Anxiety subscale. * p b .001.
met, with neuroticism being significantly associated with all symptom measures (see Step 1, Path c, in Table 3). The second condition is that the independent variable (neuroticism) is significantly related to the mediators, which was also met (Step 2, Path a). While uncontrolled betas are reported, neuroticism explained unique variance in each IUS subscale even when controlling for the other mediator. The third
Table 3
PSWQ
PA
PIsqrt
PA
BSQ/ACQ
IA
SPS/SIAS
IA
BDI-II
IA
Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step
1: 2: 3: 4: 1: 2: 3: 4: 1: 2: 3: 4: 1: 2: 3: 4: 1: 2: 3: 4:
Path c Path a Path b Path c' Path c Path a Path b Path c' Path c Path a Path b Path c' Path c Path a Path b Path c' Path c Path a Path b Path c'
1.84 .96 .61 1.26 .22 .96 .07 .16 1.22 .71 .65 .76 2.02 .71 1.36 1.06 1.81 .71 .85 1.21
.15 .10 .09 .17 .03 .10 .02 .03 .18 .07 .13 .20 .26 .07 .19 .28 .17 .07 .13 .19
.56* .49* .36* .38* .38* .49* .23* .27* .36* .49* .28* .23* .40* .49* .39* .21* .51* .49* .34* .34*
Note. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SPS = Social Phobia Scale, SIAS= Social Interaction Anxiety Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression Inventory, PA= Prospective Anxiety, IA = Inhibitory Anxiety. Path c = neuroticism-predicting symptoms, Path a = neuroticismpredicting mediator, Path b = mediator-predicting symptoms, Path c'= neuroticism-predicting symptoms controlling for the mediator. * p b .001.
condition is that the mediators explain a significant proportion of variance in the dependent variables (i.e., symptom measures). This condition was also met, with prospective anxiety explaining unique variance in PSWQ and PIsqrt, and inhibitory anxiety explaining unique variance in ACQ/BSQ, SPS/SIAS, and BDI-II (Step 3, Path b). The fourth condition is that the relationship between the independent variable and the dependent variable reduces in magnitude when controlling for the influence of the mediator. This condition was also met, with all associations between neuroticism and symptom measures reducing when controlling for the mediator. However, all direct relationships between neuroticism and the predictors remained significant, which is indicative of partial rather than full mediation (Step 4, Path c). The mediation model is depicted in Figure 1. Preacher and Hayes's (2004) method of calculating Sobel's test for the significance of the indirect effects was used, and bootstrapping with 5,000 resamples was used to calculate confidence intervals around the standardized indirect effect. The results of this analysis indicated a significant reduction in the relationship between neuroticism and all symptom measures once intolerance of uncertainty was accounted for (see Table 4). The indirect effect was strongest for the PSWQ, accounting for 20% of the variance, followed by the BDI-II (17%), SPS/SIAS (13%), BSQ/ACQ (9%), and PIsqrt (9%). Confidence intervals around the standardized indirect effects showed that the effect was significantly stronger for the PSWQ than the other symptom measures, which did not significantly differ from each other. In order to control for the influence of other symptom measures the indirect effects were recalculated controlling for all symptom measures sharing the same mediator using Preacher and Hayes's (2008) method. Standardized indirect effects remained statistically significant for the
540
.36* Prospective Anxiety .49* .38* (.56*) .27* (.38*) EPQ-N .23* (.36*) .21* (.40*) .49* .34* (.51*) .28* .39* Inhibitory Anxiety .34* .23*
PSWQ
PIsqrt
ACQ/BSQ
SPS/SIAS
BDI-II
FIGURE 1 Meditational model. Mediational pathways are bolded, whereas direct effects of neuroticism on symptoms are not. Beta coefficients in parentheses are direct effects of neuroticism on the respective symptom measure, prior to controlling for the mediator. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SIAS = Social Interaction Anxiety Scale, SPS = Social Phobia Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression InventoryII, EPQ-N = Eysenck Personality Questionnaire Neuroticism subscale. * p b .001
PSWQ, .14, 95% CI [.09.21]; PI, .05, 95% CI [.02.10]; BSQ/ACQ, .04, 95% CI [.01.07]; SPS/SIAS, .10, 95% CI [.05.16]; and BDI, .06, 95% CI [.03.11]. In these models the indirect effect for the PSWQ was only significantly stronger than that for the BSQ/ACQ, but not the other symptom measures. As a final conservative test the indirect effects were calculated again controlling for all symptom measures and effects remained statistically significant for the PSWQ, .09, 95% CI [.04.14]; PI, .02, 95% CI [.0001.06]; BSQ/ACQ, .02, 95% CI [.003.05]; SPS/SIAS, .05, 95% CI [.01.10]; and BDI, .09, 95% CI [.05.14]. In these
Discussion
IU has traditionally been examined within the context of GAD and worry. However, recent research suggests that IU may be an important contributor to symptoms across the anxiety disorders and depression. This is the first study to examine whether IU mediated the relationship between neuroticism and symptoms of social phobia, PD/A, GAD, OCD, and depression in a single treatmentseeking clinical sample. Moreover, this study sought
Table 4
Note. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SPS = Social Phobia Scale, SIAS = Social Interaction Anxiety Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression Inventory. CI = Confidence Interval, LL = Lower Limit, UL = Upper Limit. a Percent of variance in the criterion variable explained by the indirect effect. * p b .01, ** p b .001.
541
therefore that RNT is a transdiagnostic cognitive construct (Harvey, Watkins, Mansell, & Shafran, 2004). While the relationship between IU and worry has been well documented, the relationships between IU and other forms of RNT require further investigation, especially in diagnostically heterogeneous samples. If IU is strongly related to the underlying construct of RNT, then it may be more strongly associated with worry, depressive rumination, and postevent processing, compared to other physical, emotional, behavioral, and even cognitive symptoms, irrespective of diagnosis. Future research could examine this possibility by testing whether IU mediates the relationship between neuroticism and various measures of RNT to a similar degree. Furthermore, if IU leads to RNT, then RNT may mediate the relationship between IU and other symptoms of anxiety and depressive disorders. Taken together, such findings would argue that IU is a relatively specific vulnerability factor for RNT, rather than necessarily being particular to GAD. Consistent with this possibility, Yook, Kim, Suh, and Lee (2010) found that IU was correlated with both worry and depressive rumination in a clinical sample with MDD and/or GAD. Furthermore, meditational analyses showed that worry partially mediated the relationship between IU and anxiety symptoms, and rumination fully mediated the relationship between IU and depression. Despite the fact that in this study IU mediated the relationship between neuroticism and worry most strongly, IU also significantly mediated this relationship for all other symptom measures. These results are consistent with previous research finding significant associations with symptoms related to panic disorder (Carleton, Sharpe, et al., 2007; Dugas et al., 2001), social phobia (Boelen & Reijntjes, 2009; Carleton et al., 2010; Riskind et al., 2007), OCD (Holaway et al., 2006; Lind & Boschen, 2009; Tolin et al., 2003), and depression (de Jong-Meyer et al., 2009; Dugas et al., 2004; van der Heiden et al., 2010). Importantly, some of these previous studies have found that IU is uniquely associated with symptom measures even after controlling for other factors theoretically posited to also contribute to symptoms, such as metacognitions, cognitive avoidance, negative problem orientation, fear of negative evaluation, perfectionism, responsibility appraisals, anxiety sensitivity, positive and negative affectivity, self-esteem, and other symptom measures. Notwithstanding these findings, it is important for future studies to examine the degree to which IU explains unique variance in symptoms across the internalizing disorders, above and beyond other maintaining factors articulated in diagnosis-specific and indeed transdiagnostic models. For instance, it may be that
542
the variance explained by IU in the BSQ and ACQ here is better explained by a combination of other constructs in well-established models of panic disorder, such as anxiety sensitivity, catastrophic misinterpretations of physical sensations, coping selfefficacy, avoidance, and the use of safety-seeking behaviors (e.g., Casey, Oei, & Newcombe, 2004; Clark, 1986). Another avenue for future research is to investigate IU in relation to areas of core concern across diagnoses, rather than as a trait variable. Carleton, Sharpe, et al. (2007) speculated that the association between anxiety sensitivity and IU may be an intolerance of uncertainty regarding the meaning of physical symptoms of anxiety. For instance, it may be that individuals with PD/A are particularly intolerant of the possibility that an increase in their heart rate might signal an impending heart attack, and that this specific vulnerability might be more strongly related to panic symptoms than trait IU. Likewise, an individual with social phobia may be particularly intolerant of uncertainty about potential social catastrophes. If IU were assessed in relation to diagnosis-specific fears, then the associations may be stronger than those found in this study. In contrast to our findings, several studies have found evidence against a strong unique association between panic disorder symptoms and the IUS. In a sample with noncomorbid panic disorder, Dugas et al. (2005) found that IU was not significantly associated with the same measures of panic symptoms that were used in this study. Likewise, de Jong-Meyer et al. (2009) found that IU and metacognitions were associated with worry but not with panic sensations, as measured by the BAI. The BAI is predominantly a measure of somatic symptoms of anxiety that has been found to be more strongly related to panic disorder than other anxiety disorders (Cox, Cohen, Direnfeld, & Swinson, 1996). Consistent with our findings, Sexton et al. (2003) found that IU mediated the relationship between neuroticism and worry and that neuroticism had a direct relationship with OCD, panic, and worry. In contrast to our findings, however, IU did not mediate the relationship for either OCD or panic symptoms. There are a few potential explanations for the discrepancy between these findings and our results. First, Dugas et al.'s (2005), de Jong-Meyer et al.'s (2009), and Sexton et al.'s (2003) studies had substantially smaller sample sizes (N = 45, 71, and 91, respectively), thus having considerably less power to detect true associations than the current study did (n = 319). Second, having a larger sample may have reduced the influence of range attenua-
543
neous activities). Such strategies, in conjunction with a rationale for increasing tolerance of uncertainty, could be easily incorporated into existing CBT protocols. Evidence that IU is a transdiagnostic maintaining factor is accumulating. Consistent with this body of research, our study demonstrated that different aspects of IU mediated the relationship between neuroticism and a broad array of disorder-related symptoms in a treatment-seeking sample. Future research simultaneously testing multiple theoretically prescribed mediators across the internalizing disorders would be useful to identify the relative contributions of each one to various manifestations of psychopathology. If IU continues to explain unique variance in symptoms across the anxiety and depressive disorders in such models, it would be confirmed as a robust transdiagnostic maintaining factor. It is conceivable that, together with research on other transdiagnostic mechanisms, these findings could guide the development of a transdiagnostic treatment protocol that efficiently and effectively impacts on symptoms of primary and comorbid conditions.
References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Andrews, G., & Peters, L. (1998). The psychometric properties of the Composite International Diagnostic Interview. Social Psychiatry and Psychiatric Epidemiology, 33, 8088. Baron, R. M., & Kenny, D. A. (1986). The moderatormediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 6, 11731182. Barrett, P. T., Petrides, K. V., Eysenck, S. B. G., & Eysenck, H. J. (1998). The Eysenck Personality Questionnaire: An examination of the factorial similarity of P, E, N, and L across 34 countries. Personality and Individual Differences, 25, 805819. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II manual. New York: Harcourt Brace Janovich. Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23, 10111023. Berenbaum, H., Bredemeier, K., & Thompson, R. J. (2008). Intolerance of uncertainty: Exploring its dimensionality and associations with need for cognitive closure, psychopathology, and personality. Journal of Anxiety Disorders, 22, 117125. Boelen, P. A., & Reijntjes, A. (2009). Intolerance of uncertainty and social anxiety. Journal of Anxiety Disorders, 29, 130135. Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30, 3337.
544
Buhr, K., & Dugas, M. J. (2002). The Intolerance of Uncertainty Scale: Psychometric properties of the English version. Behaviour Research and Therapy, 40, 931945. Buhr, K., & Dugas, M. J. (2006). Investigating the construct validity of intolerance of uncertainty and its unique relationship with worry. Journal of Anxiety Disorders, 20, 222236. Buhr, K., & Dugas, M. J. (2009). The role of fear of anxiety and intolerance of uncertainty in worry: An experimental manipulation. Behaviour Research and Therapy, 47, 215223. Burns, G. L. (1995). Padua InventoryWashington State University Revision. Pullman, WA: Author. Burns, G. L., Keortge, S., Formea, G., & Sternberger, L. (1996). Revision of the Padua Inventory of obsessivecompulsive disorder symptoms: Distinctions between worry, obsessions, and compulsions. Behaviour Research and Therapy, 34, 163173. Butzer, B., & Kuiper, N. A. (2006). Relationships between the frequency of social comparisons and self-concept clarity, intolerance of uncertainty, anxiety, and depression. Personality and Individual Differences, 41, 167176. Carleton, R. N., Collimore, K. C., & Asmundson, G. (2010). It's not just the judgmentsIt's that I don't know: Intolerance of uncertainty as a predictor of social anxiety. Journal of Anxiety Disorders, 24, 189195. Carleton, R. N., Norton, P. J., & Asmundson, G. (2007). Fearing the unknown. A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105117. Carleton, R. N., Sharpe, D., & Asmundson, G. J. G. (2007). Anxiety sensitivity and intolerance of uncertainty: Requisites of the fundamental fears? Behaviour Research and Therapy, 45, 23072316. Caruso, J. C., Witkiewitz, K., Belcourt-Dittloff, A., & Gottlieb, J. D. (2001). Reliability of scores from the Eysenck Personality Questionnaire: A reliability generalization study. Educational and Psychological Measurement, 61, 675689. Casey, L. M., Oei, T. P. S., & Newcombe, P. A. (2004). An integrated cognitive model of panic disorder: The role of positive and negative cognitions. Clinical Psychology Review, 24, 529555. Chambless, D. L., Beck, A. T., Gracely, E. J., & Grisham, J. R. (2000). Relationship of cognitions to fear of somatic symptoms: A test of the cognitive theory of panic. Depression and Anxiety, 11, 19. Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 10901097. Chambless, D. L., & Gracely, E. J. (1989). Fear of fear and the anxiety disorders. Cognitive Therapy and Research, 13, 920. Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461470. Cox, B. J., Cohen, E., Direnfeld, D. M., & Swinson, R. P. (1996). Does the Beck Anxiety Inventory measure anything beyond panic attack symptoms? Behaviour Research and Therapy, 34, 949954. Cox, B. J., Ross, L., Swinson, R. P., & Direnfeld, D. M. (1998). A comparison of social phobia outcome measures in cognitivebehavioral therapy. Behavior Modification, 22, 285297. de Jong-Meyer, R., Beck, B., & Riede, K. (2009). Relationships between rumination, worry, intolerance of uncertainty and metacognitive beliefs. Personality and Individual Differences, 46, 547551. Dozois, D. J. A., Dobson, K. S., & Ahnberg, J. L. (1998). A psychometric evaluation of the Beck Depression InventoryII. Psychological Assessment, 10, 8389.
545
tion models. Behaviour Research Methods, Instruments, and Computers, 36, 717731. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879891. Riskind, J. H., Tzur, D., Williams, N. L., Mann, B., & Shahar, G. (2007). Short-term predictive effects of the looming cognitive style on anxiety disorder symptoms under restrictive methodological conditions. Behaviour Research and Therapy, 45, 17651777. Rosen, N. O., & Knuper, B. (2009). A little uncertainty goes a long way: State and trait differences in uncertainty interact to increase information seeking but also increase worry. Health Communication, 24, 228238. Sexton, K. A., Norton, P. J., Walker, J. R., & Norton, G. R. (2003). Hierarchical model of generalized and specific vulnerabilities in anxiety. Cognitive Behaviour Therapy, 32, 8294. Starcevic, V., & Berle, D. (2006). Cognitive specificity of anxiety disorders: A review of selected key constructs. Depression and Anxiety, 23, 5161. Steketee, G., Frost, R. O., & Cohen, I. (1998). Beliefs in obsessive-compulsive disorder. Journal of Anxiety Disorders, 12, 525537. Tolin, D., Abramowitz, J. S., Brigidi, B. D., & Foa, E. B. (2003). Intolerance of uncertainty in obsessive-compulsive disorder. Journal of Anxiety Disorders, 17, 233242. van der Heiden, C., Melchoir, K., Muris, P., Bouwmeester, S., Bos, A. E. R., & van der Molen, H. T. (2010). A hierarchical model for the relationships between general and specific vulnerability factors and symptom levels of generalized anxiety disorder. Journal of Anxiety Disorders , 24 , 284289. van Rijsoort, S., Emmelkamp, P., & Vervaeke, G. (1999). The Penn State Worry Questionnaire and the Worry Domains Questionnaire: Structure, reliability and validity. Clinical Psychology and Psychotherapy, 6, 297307. Wittchen, H. -U. (1994). Reliability and validity studies of the WHO Composite International Diagnostic Interview (CIDI): A critical review. Journal of Psychiatric Research, 28, 5784. World Health Organization (1993). The ICD-I0 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva, Switzerland: Author. World Health Organization (1997). CIDI-auto version 2.1: Administrator's guide and reference. Sydney, Australia: Training and Reference Centre for WHO CIDI. Yook, K., Kim, K., Suh, S. Y., & Lee, K. S. (2010). Intolerance of uncertainty, worry, and rumination in major depressive disorder and generalized anxiety disorder. Journal of Anxiety Disorders, 24, 623628. R E C E I V E D : June 11, 2010 A C C E P T E D : February 23, 2011 Available online 6 June 2011