Intolerance of Uncertainty In Obsessive-Compulsive Disorder

Intolerance of uncertainty (IU) refers to difficulty tolerating uncertain situations and reacting negatively to ambiguity. It involves negative beliefs about uncertainty and strong emotional, cognitive, and behavioral responses to uncertain situations.

IU is increasingly seen as an underlying mechanism in OCD, especially in children/adolescents. When faced with unpredictable situations or unknown outcomes in the future, individuals with OCD may react with heightened feelings of anxiety, an overthinking process characterized by repetitive, unrealistic worry.

This might include worrying about a future event, thinking of all the worst-case scenarios, replaying a past scenario, predicting how something will play out, or planning something to every last detail.

Rituals, avoidance behaviors, and safety behaviors in OCD can be understood as ways for individuals to seek certainty when faced with uncertainty.

Knowles, K. A., & Olatunji, B. O. (2023). Intolerance of uncertainty as a cognitive vulnerability for obsessive-compulsive disorder: A qualitative review. Clinical Psychology: Science and Practice, 30(3), 317–330. https://doi.org/10.1037/cps0000150

Key Points

1. Intolerance of uncertainty (IU) is associated with symptoms of obsessive-compulsive disorder (OCD), but additional research is needed to determine if increasing tolerance of uncertainty is a mechanism of effective OCD treatment.
2. There is consistent evidence that IU is associated with OCD symptoms in both clinical and nonclinical samples. However, the causal role of IU in OCD development requires further research.
3. IU appears relatively stable over time, with the time-invariant (“trait”) component predicting OCD symptoms over 5 months in one study. However, stability beyond this timeframe is unknown.
4. Experimental studies have manipulated uncertainty beliefs, increasing state IU and negative beliefs about uncertainty. Two studies found effects on OCD symptoms, suggesting beliefs are malleable. However, the duration of these effects is unclear.
5. IU improves after OCD treatment, and changes in IU are associated with OCD symptom changes, but no studies have isolated IU as a treatment mechanism. More rigorous research on IU interventions for OCD is needed.

Rationale

Obsessive-compulsive disorder is characterized by intrusive thoughts and repetitive behaviors aimed at reducing distress and preventing perceived threats (American Psychiatric Association, 2013).

Cognitive models highlight maladaptive beliefs as risk factors, including intolerance of uncertainty, or difficulty tolerating uncertain situations (Steketee et al., 1998; Tolin et al., 2003).

Intolerance of uncertainty has been frequently studied in relation to worry and generalized anxiety disorder (Dugas et al., 2004).

However, its role as a cognitive vulnerability specifically implicated in the development and maintenance of OCD requires additional empirical examination (Gentes & Ruscio, 2011).

Establishing intolerance of uncertainty as a causal risk factor for OCD can facilitate translational research and inform treatment development (Einstein, 2014).

Method

This paper reviewed the literature on intolerance of uncertainty and OCD using PsycInfo and Google Scholar. It evaluated evidence based on criteria for establishing a cognitive vulnerability (Koerner & Dugas, 2008):

1. Association with OCD symptoms
2. Stability over time
3. Role as a causal risk factor
4. Malleability to intervention

Sample

The literature reviewed included clinical and nonclinical samples with a range of OCD severities and symptom profiles.

Studies frequently compared OCD samples to non-anxious controls. Some studies also included samples with other anxiety disorders.

Statistical Analysis

Associations between intolerance of uncertainty and OCD symptoms were typically examined through correlation and regression analyses.

Manipulation studies used ANOVA to test group differences in OCD symptoms after the uncertainty induction. Within-subject effect sizes were also reported.

Results

Association with OCD symptoms

• Moderate to strong associations between IU and OCD symptoms were consistently found (meta-analyses: Gentes & Ruscio, 2011; McEvoy et al., 2019).
• IU prospectively predicted OCD symptoms in parents and adolescents (Abramowitz et al., 2006; Pozza et al., 2019).
• IU is associated with behavioral analogs of OCD symptoms (e.g., checking, contamination concerns) in nonclinical student samples (Sarawgi et al., 2013).

Stability over time

• Test-retest reliability over 2-5 weeks is good for IUS-12 and IUS-27 (Buhr & Dugas, 2002; Carleton et al., 2014).
• IU stable from ages 8-11 in one longitudinal study (Hong et al., 2017).
• Time-invariant “trait” IU accounted for 76-82% of the variance in IUS scores and predicted OCD symptoms over 5 months (Knowles et al., 2022).

Role as a causal risk factor

• Mixed evidence that changes in IU precede changes in OCD symptoms over treatment (Su et al., 2016; Wilhelm et al., 2015).
• Manipulating uncertainty beliefs increased negative beliefs about uncertainty and state IU (Deschenes et al., 2010; Mosca et al., 2016).
• Two manipulation studies found effects on self-reported OCD symptoms (Faleer et al., 2017; Geok et al., 2022).

Malleability to intervention

• IU improves after cognitive and behavioral treatments for OCD, with moderate to large effects (Belloch et al., 2010; Mathur et al., 2021; Su et al., 2016).
• Greater changes in IU are associated with greater reductions in OCD symptoms during treatment (Pinciotti et al., 2020; Wilhelm et al., 2015).
• No studies have isolated increasing tolerance of uncertainty as a treatment mechanism.

Insight

This review highlights the need for additional rigorous tests of intolerance of uncertainty as a causal risk factor for OCD using longitudinal and experimental designs.

Understanding developmental pathways and multimodal correlates can further elucidate the role of intolerance of uncertainty in OCD.

If increasing tolerance of uncertainty proves to be a mechanism of effective OCD treatment, directly targeting intolerance of uncertainty in therapies may improve outcomes for this difficult-to-treat disorder.

Strengths

• The literature review was comprehensive, examining multiple types of studies relevant to the question of whether intolerance of uncertainty meets criteria as a cognitive vulnerability for OCD.
• It focused on studies using validated measures of intolerance of uncertainty.
• The review specifically considered OCD rather than emotional disorders broadly.

Limitations

• The majority of studies were cross-sectional. Few experimental studies tested effects on OCD symptoms specifically.
• No studies isolated intolerance of uncertainty as a mechanism of treatment change.
• Samples were predominantly North American and European.

Implications

This review suggests intolerance of uncertainty likely contributes to OCD but may not fully explain its onset and maintenance across the lifespan.

Both cognitive and behavioral approaches to target intolerance of uncertainty warrant additional study as a potential focus within CBT for OCD.

Changes in intolerance of uncertainty over the course of development, especially from early childhood to disorder onset, require examination.

Clinical Practice

• Use validated measures like the Intolerance of Uncertainty Scale (IUS-12) to assess IU and determine if it is a clinical focus. The IUS-12 captures both prospective and inhibitory IU.
• Teach distress tolerance skills, as an inability to tolerate uncertainty arousal may maintain compulsions.
• Programs targeting IU in at-risk youth could potentially prevent or delay OCD onset. This could include CBT or childhood interventions like modeling tolerance of uncertainty.
• Psychoeducation for families about the role of IU in OCD can provide a shared language and allow identification of other IU manifestations in daily life that may present treatment targets. Parent modeling of tolerating uncertainty can help children build this skill.
• OCD treatment exposure can be adapted to specifically target IU, either through general uncertainty exposures or by layering uncertainty into exposures that target core obsessions.

Conclusion

Overall, intolerance of uncertainty meets many but not all criteria for a cognitive vulnerability for OCD based on the literature to date.

There is a clear association with OCD symptoms and evidence of relative stability. However, more rigorous tests of the causal role of intolerance of uncertainty in OCD and isolation as a mechanism of effective treatment are needed.

Developing and testing interventions that specifically target intolerance of uncertainty in OCD patients would significantly advance this literature.

Understanding the complex role intolerance of uncertainty plays in this debilitating disorder may inform translational research on both etiology and treatment.

References

• Abramowitz, J. S., Khandker, M., Nelson, C. A., Deacon, B. J., & Rygwall, R. (2006). The role of cognitive factors in the pathogenesis of obsessive–compulsive symptoms: A prospective study. Behaviour Research and Therapy, 44(9), 1361-1374. https://doi.org/10.1016/j.brat.2005.09.011
• Belloch, A., Cabedo, E., Carrió, C., & Larsson, C. (2010). Cognitive therapy for autogenous and reactive obsessions: Clinical and cognitive outcomes at post-treatment and 1-year follow-up. Journal of Anxiety Disorders, 24(6), 573-580. https://doi.org/10.1016/j.janxdis.2010.03.017
• Buhr, K., & Dugas, M. J. (2002). The intolerance of uncertainty scale: Psychometric properties of the English version. Behaviour Research and Therapy, 40(8), 931-945. https://doi.org/10.1016/S0005-7967(01)00092-4
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Carleton, R. N., Thibodeau, M. A., Osborne, J. W., & Taylor, S. (2014). Revisiting the fundamental fears: Toward establishing construct independence. Personality and Individual Differences, 63, 94-99. https://doi.org/10.1016/j.paid.2014.01.040
• Deschenes, S. S., Dugas, M. J., Radomsky, A. S., & Buhr, K. (2010). Experimental manipulation of beliefs about uncertainty: Effects on interpretive processing and access to threat schemata. Journal of Experimental Psychopathology, 1(1), Article jep.008510. https://doi.org/10.5127/jep.008510
• Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy, 36(2), 215-226. https://doi.org/10.1016/S0005-7967(97)00070-3
• Einstein, D. A. (2014). Extension of the transdiagnostic model to focus on intolerance of uncertainty: A review of the literature and implications for treatment. Clinical Psychology: Science and Practice, 21(3), 280-300. https://doi.org/10.1111/cpsp.12077
• Faleer, H. E., Fergus, T. A., Bailey, B. E., & Wu, K. D. (2017). Examination of an experimental manipulation of intolerance of uncertainty on obsessive-compulsive outcomes. Journal of Obsessive-Compulsive and Related Disorders, 15, 64-73. https://doi.org/10.1016/j.jocrd.2017.07.002
• Gentes, E. L., & Ruscio, A. M. (2011). A meta-analysis of the relation of intolerance of uncertainty to symptoms of generalized anxiety disorder, major depressive disorder, and obsessive-compulsive disorder. Clinical Psychology Review, 31(6), 923-933. https://doi.org/10.1016/j.cpr.2011.05.001
• Geok, E.-T., Lee, K. Y. C., & Sündermann, O. (2022). An experimental investigation of intolerance of uncertainty and its impact on sub-clinical psychopathology. Journal of Behavior Therapy and Experimental Psychiatry, 75, Article 101718. https://doi.org/10.1016/j.jbtep.2021.101718
• Hong, R. Y., Lee, S. S. M., Tsai, F.-F., & Tan, S. H. (2017). Developmental trajectories and origins of a core cognitive vulnerability to internalizing symptoms in middle childhood. Clinical Psychological Science, 5(2), 299–315. https://doi.org/10.1177/2167702616679875
• Knowles, K. A., Cole, D. A., Cox, R. C., & Olatunji, B. O. (2022). Time-varying and time-invariant dimensions in intolerance of uncertainty: Specificity in the prediction of obsessive-compulsive symptoms. Behavior Therapy, 53(4), 686-700. https://doi.org/10.1016/j.beth.2022.01.012
• Koerner, N., & Dugas, M. J. (2008). An investigation of appraisals in individuals vulnerable to excessive worry: The role of intolerance of uncertainty. Cognitive Therapy and Research, 32(5), 619-638. https://doi.org/10.1007/s10608-007-9125-2
• Mathur, S., Sharma, M. P., Balachander, S., Kandavel, T., & Reddy, Y. C. J. (2021). A randomized controlled trial of mindfulness-based cognitive therapy vs stress management training for obsessive-compulsive disorder. Journal of Affective Disorders, 282, 58-68. https://doi.org/10.1016/j.jad.2020.12.082
• McEvoy, P. M., Hyett, M. P., Shihata, S., Price, J. E., & Strachan, L. (2019). The impact of methodological and measurement factors on transdiagnostic associations with intolerance of uncertainty: A meta-analysis. Clinical Psychology Review, 73, Article 101778. https://doi.org/10.1016/j.cpr.2019.101778
• Mosca, O., Lauriola, M., & Carleton, R. N. (2016). Intolerance of uncertainty: A temporary experimental induction procedure. Plos One, 11(6), Article e0155130. https://doi.org/10.1371/journal.pone.0155130
• Pinciotti, C. M., Riemann, B. C., & Wetterneck, C. T. (2020). Differences in intolerance of uncertainty in OCD and comorbid PTSD underlying attenuated treatment response. Annals of Psychiatry and Mental Health, 8(1), 1142. https://www.jscimedcentral.com/Psychiatry/psychiatry-8-1142.pdf
• Pozza, A., Albert, U., & Dèttore, D. (2019). Perfectionism and intolerance of uncertainty are predictors of OCD symptoms in children and early adolescents: A prospective, cohort, one-year, follow-up study. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 16(1), 53-61.
• Sarawgi, S., Oglesby, M. E., & Cougle, J. R. (2013). Intolerance of uncertainty and obsessive-compulsive symptom expression. Journal of Behavior Therapy and Experimental Psychiatry, 44(4), 456-462. https://doi.org/10.1016/j.jbtep.2013.06.001
• Steketee, G., Frost, R. O., & Cohen, I. (1998). Beliefs in obsessive-compulsive disorder. Journal of Anxiety Disorders, 12(6), 525-537. https://doi.org/10.1016/S0887-6185(98)00030-9
• Su, Y.-J., Carpenter, J. K., Zandberg, L. J., Simpson, H. B., & Foa, E. B. (2016). Cognitive mediation of symptom change in exposure and response prevention for obsessive-compulsive disorder. Behavior Therapy, 47(4), 474-486. https://doi.org/10.1016/j.beth.2016.03.003
• Tolin, D. F., Abramowitz, J. S., Brigidi, B. D., & Foa, E. B. (2003). Intolerance of uncertainty in obsessive-compulsive disorder. Journal of Anxiety Disorders, 17(2), 233-242. https://doi.org/10.1016/S0887-6185(02)00182-2
• Wilhelm, S., Berman, N. C., Keshaviah, A., Schwartz, R. A., & Steketee, G. (2015). Mechanisms of change in cognitive therapy for obsessive compulsive disorder: Role of maladaptive beliefs and schemas. Behaviour Research and Therapy, 65, 5-10. https://doi.org/10.1016/j.brat.2014.12.006

Further Reading

Einstein, D. A. (2014). Extension of the transdiagnostic model to focus on intolerance of uncertainty: a review of the literature and implications for treatment. Clinical Psychology: Science and Practice, 21(3), 280.

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