Intolerance of Uncertainty and OCD Symptom Severity: The Role of Emotion-Related Impulsivity

Intolerance of uncertainty (IU) and emotion-related impulsivity are cognitive risk factors for OCD that are connected to negative emotional experiences.

IU is defined as negative beliefs about uncertainty and one’s ability to cope with it, and has been conceptualized as a central factor underlying various anxiety disorders, especially OCD.

Individuals with high IU exhibit hypervigilance towards uncertainty, leading to negative emotional arousal and obsessions. They tend to avoid uncertain states and engage in actions to restore certainty, which can transform into compulsions over time.

The relationship between IU and OCD severity has been consistently supported in both clinical and non-clinical samples, even after controlling for comorbid symptoms.

However, the moderate strength of this association suggests that IU alone may not fully explain OCD, and the mechanistic link between them remains to be fully understood.

Xu, J., Ironside, M. L., Broos, H. C., Johnson, S. L., & Timpano, K. R. (2024). Urged to feel certain again: The role of emotion-related impulsivity on the relationships between intolerance of uncertainty and OCD symptom severity. British Journal of Clinical Psychology, 63, 258–272. https://doi.org/10.1111/bjc.12456

Key Points

• Intolerance of uncertainty (IU) and emotion-related impulsivity are cognitive risk factors that underlie OCD, and both constructs are tightly connected to one’s experience with negative emotional states.
• IU, emotion-related impulsivity and OCD symptom severity are positively associated with each other.
• Emotion-related impulsivity interacted with IU, such that higher levels of both predicted greater OCD symptom severity. This suggests how the coupling of distress brought by uncertainty and a high urge to act upon it behaviourally could be crucial in linking uncertainty to obsessions and compulsions.
• While the behavioral form of emotion-related impulsivity (Feelings Trigger Action) was a predictor of all OCD symptom domains, the cognitive form (Pervasive Influence of Feelings) was specific in predicting greater obsessing symptoms only.
• While enlightening, the research has certain limitations, such as reliance on cross-sectional data and limited diversity in the sample. Replication in clinical OCD populations would strengthen the findings.
• Understanding the cognitive risk factors of OCD has universal relevance for enhancing knowledge of the disorder’s etiology and informing more effective treatments.

Rationale

Intolerance of uncertainty (IU) has been consistently evidenced as a cognitive risk factor underlying OCD (Grayson, 2014; Tolin et al., 2003).

More recently, emotion-related impulsivity has also emerged as a transdiagnostic vulnerability factor for OCD, capturing poorer control over obsessions and compulsions (Hudiburgh et al., 2021; Kashyap et al., 2012).

Despite the strong theoretical rationale, no studies to date have examined IU and emotion-related impulsivity together in OCD to consider their potentially synergistic effects. S

parse research in related conditions like generalized anxiety disorder found that IU and negative urgency uniquely predict symptoms and mediate each other’s effects (Pawluk & Koerner, 2013, 2016).

Building on this evidence, the present study sought to examine the interaction between IU and emotion-related impulsivity in predicting OCD symptom severity. (Word count: 129)

Method

This study utilized a cross-sectional design with data collected online from community-based adult participants.

Linear regression models were used to examine the interaction effects between intolerance of uncertainty and two forms of emotion-related impulsivity (Feelings Trigger Action and Pervasive Influence of Feelings) in predicting overall OCD symptom severity as well as specific symptom domains.

Participants completed a battery of self-report questionnaires administered online through Qualtrics after providing informed consent.

The questionnaires assessed OCD symptom severity, intolerance of uncertainty, and emotion-related impulsivity.

Sample

The final sample included 673 community-based adults (Sample 1 n=252, Sample 2 n=421) recruited from Amazon’s Mechanical Turk. The mean age was 36.2 years (SD=11.2). Gender composition was 45.3% female, 53.7% male, and 0.4% other. The majority of participants (77.0%) were Caucasian/White. There were no significant differences between the two subsamples on demographic characteristics.

Measures

• Obsessive-Compulsive Inventory-12 Items (OCI-12): Assesses OCD symptom severity across four domains – checking, ordering, washing, and obsessing. Has evidenced good psychometric properties.
• Intolerance of Uncertainty Scale-Short Version (IUS-12): Measures reactions to uncertainty and ambiguous situations. Has demonstrated high reliability and validity.
• Three-Factor Impulsivity Index (TFII): Assesses emotion-related impulsivity through two subscales – Feelings Trigger Action (behavioural responses to emotions) and Pervasive Influence of Feelings (cognitive/motivational responses to emotions). Both subscales have shown high internal consistency.

Statistical Measures

Stepwise linear regression models were used to examine the interaction effects. Intolerance of uncertainty, Feelings Trigger Action, Pervasive Influence of Feelings, and their interaction terms were entered as predictors.

The dependent variables were OCD total symptom severity in the primary model and specific OCD symptom domains (checking, ordering, washing, obsessing) in exploratory models.

Sample was included as a covariate. Multicollinearity was assessed and found acceptable. Simple slopes analyses probed significant interactions.

Results

• Intolerance of uncertainty, Feelings Trigger Action, and Pervasive Influence of Feelings each positively predicted overall OCD symptom severity.
• There was a significant interaction between intolerance of uncertainty and Feelings Trigger Action, such that OCD symptoms were most severe when individuals were high in both factors. Simple slopes indicated intolerance of uncertainty more strongly predicted OCD severity at high versus low levels of Feelings Trigger Action.
• The interaction between intolerance of uncertainty and Feelings Trigger Action significantly predicted checking, washing and obsessing symptoms. Again, symptoms were most severe at high levels of both factors, particularly for obsessing.
• In contrast, the interaction between intolerance of uncertainty and Pervasive Influence of Feelings was not significant in predicting overall OCD severity or most symptom domains (except checking, where the finding was small and requires replication).
• Pervasive Influence of Feelings still emerged as a unique predictor of obsessing symptoms specifically, even after accounting for intolerance of uncertainty and Feelings Trigger Action.

Insight

The study provides novel insights into how intolerance of uncertainty and emotion-related impulsivity jointly contribute to OCD symptom severity.

Specifically, the behavioral urge to immediately act on distress (captured by Feelings Trigger Action) appears to amplify the pathway from uncertainty-related distress to OCD symptoms, particularly compulsions like checking/washing and obsessive thoughts.

In other words, when faced with the uncomfortable experience of uncertainty, those who tend to reflexively act on that discomfort through impulsive behaviours may engage in more frequent compulsions and obsessive thoughts as attempts to alleviate the distress and restore a sense of certainty.

In contrast, the cognitive impact of emotions (Pervasive Influence of Feelings) does not seem to interact with intolerance of uncertainty, though it is still uniquely associated with obsessing symptoms.

This distinction suggests that behavioral impulsivity in the context of distress may be especially relevant for promoting a wider range of OCD symptoms, whereas cognitive forms of emotion-driven impulsivity relate more specifically to obsessive thoughts.

These findings extend previous research by elucidating the synergistic cognitive-emotional processes that may underlie the development and maintenance of OCD.

They highlight intolerance of uncertainty and emotion-related impulsivity, especially the behavioral component, as potential risk factors that interact to predict greater OCD severity.

This interplay between distress intolerance and the urge to act on that distress through maladaptive behaviors may represent an important treatment target.

Future research could build on these cross-sectional findings by examining the temporal dynamics between these constructs and OCD symptoms over time.

Experimental designs that induce uncertainty and assess real-time emotional and behavioral responses could provide further mechanistic insights.

Extending this research to clinical OCD populations is also an important next step to determine the clinical utility of targeting intolerance of uncertainty and emotion-driven impulsivity in treatment.

Strengths

• Large sample size (N=673) enhancing statistical power
• Use of well-validated measures of intolerance of uncertainty, emotion-related impulsivity and OCD symptoms
• Novel examination of the interaction between two previously separate cognitive risk factors for OCD
• Exploratory analyses to probe specific OCD symptom domains
• Accounting for potential cohort effects by controlling for sample

Limitations

• The cross-sectional design precludes causal conclusions about the direction of effects between intolerance of uncertainty, emotion-related impulsivity and OCD symptoms. Longitudinal research is needed.
• The study used a non-clinical, community sample. While there was good variability in OCD symptom severity, most participants had mild symptoms. Replication in clinical OCD populations is necessary to establish generalizability.
• The sample had limited racial/ethnic diversity (76.7% White). Previous research suggests lower intolerance of uncertainty among racial minorities compared to White individuals (Sadeh & Bounoua, 2023), so current findings may not generalize to more diverse populations.
• Exclusive use of self-report measures is a potential limitation. Incorporating behavioral/physiological indices of distress and impulsivity would provide a more comprehensive assessment.

The limited diversity and non-clinical nature of the sample restrict the generalizability of the findings to clinical OCD populations and those from underrepresented racial/ethnic backgrounds.

The cross-sectional methodology also limits inferences about how these risk factors dynamically influence each other and OCD symptoms over time.

Addressing these limitations through longitudinal clinical research with diverse samples is an important future direction.

Clincal Implications

The results underscore the significance of both intolerance of uncertainty and emotion-related impulsivity as cognitive risk factors for OCD.

The interaction effect whereby greater intolerance of uncertainty predicted more severe OCD symptoms (particularly checking, washing, obsessing) among those also high in emotion-driven behavioral impulsivity has notable clinical implications.

It suggests that this combination of distress in response to uncertainty coupled with the urge to reflexively act on that distress through compulsive behaviors may be an especially potent pathway to OCD symptoms.

As such, targeting distress tolerance skills and techniques to sit with uncomfortable uncertainty without immediately acting on it may be important treatment components.

Intolerance of uncertainty and emotion-related impulsivity also appear to have somewhat distinct relevance to obsessions versus compulsions.

The behavioral component of impulsivity (Feelings Trigger Action) interacted with intolerance of uncertainty to predict both thoughts and behaviors, whereas the cognitive component (Pervasive Influence of Feelings) uniquely predicted obsessional symptoms only.

This highlights the potential utility of targeting different skills (behavioral response prevention versus cognitive restructuring) based on an individual’s primary symptom presentation.

Of note, while the study used a non-clinical sample, the effects were apparent across the spectrum of OCD symptom severity.

This has implications for prevention efforts, as even subclinical OCD symptoms are associated with substantial functional impairment (Adam et al., 2012; Angst et al., 2004).

Early interventions to build uncertainty tolerance and emotion regulation skills may help mitigate the progression from mild to severe symptoms.

References

Primary reference

Xu, J., Ironside, M. L., Broos, H. C., Johnson, S. L., & Timpano, K. R. (2024). Urged to feel certain again: The role of emotion-related impulsivity on the relationships between intolerance of uncertainty and OCD symptom severity. British Journal of Clinical Psychology, 63, 258–272. https://doi.org/10.1111/bjc.12456

Other references

Adam, Y., Meinlschmidt, G., Gloster, A. T., & Lieb, R. (2012). Obsessive-compulsive disorder in the community: 12-month prevalence, comorbidity and impairment. Social Psychiatry and Psychiatric Epidemiology, 47(3), 339–349. https://doi.org/10.1007/s00127-010-0337-5

Angst, J., Gamma, A., Endrass, J., Goodwin, R., Ajdacic, V., Eich, D., & Rössler, W. (2004). Obsessive-compulsive severity spectrum in the community: Prevalence, comorbidity, and course. European Archives of Psychiatry and Clinical Neuroscience, 254(3), 156–164. https://doi.org/10.1007/s00406-004-0459-4

Grayson, J. (2014). Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty (Updated ed.). Penguin.

Hudiburgh, S. E., Reese, H. E., Carver, C. S., Çek, D., & Timpano, K. R. (2021). A multi-method examination of the link between obsessive-compulsive symptomatology and emotion-related impulsivity. British Journal of Clinical Psychology, 60(3), 293–311. https://doi.org/10.1111/bjc.12290

Kashyap, H., Fontenelle, L. F., Miguel, E. C., Ferrão, Y. A., Torres, A. R., Shavitt, R. G., Ferreira- Garcia, R., do Rosário, M. C., & Yücel, M. (2012). ‘Impulsive compulsivity’ in obsessive- compulsive disorder: A phenotypic marker of patients with poor clinical outcome. Journal of Psychiatric Research, 46(9), 1146–1152. https://doi.org/10.1016/j.jpsychires.2012.04.022

Pawluk, E. J., & Koerner, N. (2013). A preliminary investigation of impulsivity in generalized anxiety disorder. Personality and Individual Differences, 54(6), 732–737. https://doi.org/10.1016/j.paid.2012.11.027

Pawluk, E. J., & Koerner, N. (2016). The relationship between negative urgency and generalized anxiety disorder symptoms: The role of intolerance of negative emotions and intolerance of uncertainty. Anxiety, Stress, and Coping, 29(6), 606–615. https://doi.org/10.1080/10615806.2015.1134786

Sadeh, N., & Bounoua, N. (2023). Race moderates the impact of intolerance of uncertainty on mental health symptoms in Black and White community adults. Journal of Anxiety Disorders, 93, 102657. https://doi.org/10.1016/j.janxdis.2022.102657

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

Keep Learning

• How might the distinct behavioral versus cognitive components of emotion-related impulsivity relate to different treatment approaches for OCD (e.g., exposure and response prevention versus cognitive restructuring)? What are the potential pros and cons of targeting these aspects of impulsivity?
• The study found that intolerance of uncertainty and emotion-related impulsivity interacted to predict OCD severity in a non-clinical sample. To what extent do you think these findings would generalize to individuals with clinically diagnosed OCD? What additional factors might be important to consider in a clinical population?
• Imagine you are a clinician developing a treatment plan for a client with primary contamination/washing symptoms who reports high intolerance of uncertainty and emotion-driven behavioral impulsivity. How would you incorporate the insights from this study into your case conceptualization and treatment approach? What specific skills or techniques might you prioritize?
• The authors note the limited racial/ethnic diversity of their sample as a potential limitation. Why is it important to study these constructs in diverse populations? What are some ways that cultural factors could influence the experience and expression of intolerance of uncertainty, emotion-related impulsivity, and OCD symptoms?
• The study used a cross-sectional design, which limits conclusions about the direction of effects between the variables. How would you design a longitudinal study to build on these findings and examine the temporal relationships between intolerance of uncertainty, emotion-related impulsivity, and OCD symptoms over time? What time intervals and assessment points would be most informative?