Generalized anxiety disorder (GAD) is marked by excessive worries, often related to health and future uncertainties.
Intolerance of uncertainty may lead individuals with GAD to worry about potential health problems beyond their control, such as developing a serious illness in the future.
This chronic worry about uncontrollable aspects of health can maintain and exacerbate anxiety, perpetuating the cycle of GAD symptoms.
Recognizing the role of uncertainty and health concerns in GAD provides context for understanding the disorder’s cognitive mechanisms and potential interventions.
Dugas, M. J., Giguère Marchal, K., Cormier, S., Bouchard, S., Gouin, J.‐P., & Shafran, R. (2023). Pain catastrophizing and worry about health in generalized anxiety disorder. Clinical Psychology & Psychotherapy, 30(4), 852–861. https://doi.org/10.1002/cpp.2843
Key Points
- Uncertainty about future events can lead to worry, anxiety, and impaired functioning. The concept of intolerance of uncertainty (IU) emerged in the 1990s and has been developed as a transdiagnostic risk factor for multiple anxiety disorders.
- IU is defined as cognitive, emotional, and behavioral responses to uncertainty in everyday situations. It includes perception of uncertain situations as threatening.
- IU is measured using the 27-item Intolerance of Uncertainty Scale (IUS). Factor analyses suggest IU has two dimensions: prospective IU related to cognitive processes and inhibitory IU related to behavioral responses.
- Experimental research shows uncertainty is associated with biased threat expectancies, heightened attention to uncertain threats, and impaired ability to prepare for and respond to uncertain events. Uncertainty may fuel anxiety by disrupting anticipatory processes.
- IU is associated with various emotional disorders including generalized anxiety disorder, social anxiety disorder, panic disorder, and obsessive-compulsive disorder. Disorder-specific IU may be more strongly related to symptoms than general IU.
Rationale
Diagnostic criteria for GAD emphasize excessive worry across various life domains, so most research has focused on the general tendency to worry rather than worry content (APA, 2013).
Descriptive studies in the late 1980s and 1990s found individuals with GAD worry about topics similar to those of non-clinical populations, with some exceptions like minor matters and remote future events (Craske et al., 1989; Dugas, Freeston et al., 1998; Roemer et al., 1997). However, no studies have explored predictors of specific worry topics in GAD.
Cognitive-behavioral theories of GAD primarily explain differences in overall worry levels using “threat-nonspecific” factors like intolerance of uncertainty (Dugas, Gagnon et al., 1998) and psychological rigidity (Roemer & Orsillo, 2007).
They do not systematically predict worry content, despite evidence that worry topics are relatively stable over 12 months in GAD (Constans et al., 2002).
Identifying vulnerability factors for specific worry themes could enhance understanding of individual GAD presentations and increase treatment efficacy, which remains subpar for cognitive-behavioral therapy (Hunot et al., 2010).
This study takes a step in that direction by examining the relationship between pain catastrophizing and health-related worry in GAD.
Method
This was a secondary analysis of pretest data from 60 adults with primary GAD who participated in a clinical trial.
Hypotheses tested were:
- Pain catastrophizing would positively relate to GAD severity
- This relationship would not be explained by intolerance of uncertainty and psychological rigidity
- Pain catastrophizing would be higher in participants reporting health-related worries vs. those not reporting them
Sample
60 adults with a primary diagnosis of GAD. No further demographic information provided.
Measures
- Pain Catastrophizing Scale (PCS): Assesses the extent to which individuals magnify the threat value of pain, ruminate about pain, and feel helpless in the face of pain.
- Penn State Worry Questionnaire (PSWQ): Measures the generality, excessiveness, and uncontrollability of worry.
- Intolerance of Uncertainty Scale (IUS): Evaluates emotional, cognitive, and behavioral reactions to uncertainty, ambiguous situations, and the future.
- Acceptance and Action Questionnaire-II (AAQ-II): Assesses experiential avoidance and psychological inflexibility, which involve the unwillingness to remain in contact with unwanted private experiences (e.g., thoughts, emotions, sensations) and taking action to alter them.
- Idiosyncratic Worry Topics Questionnaire (IWTQ): Measures the presence or absence of specific worry themes, including health-related worries.
Statistical Analysis
- Pearson correlations
- Partial correlations controlling for intolerance of uncertainty and psychological rigidity
- Independent samples t-test comparing pain catastrophizing in those with vs. without health-related worry
Results
- Pain catastrophizing positively correlated with GAD severity (r = .44, p < .001)
- This relationship remained significant after controlling for intolerance of uncertainty and psychological rigidity (pr = .29, p < .05)
- Pain catastrophizing was higher in those reporting health-related worry (M = 22.45) than those not reporting it (M = 14.38), t(58) = 2.76, p < .01.
All hypotheses were confirmed.
Insight
This review provides a comprehensive overview of research on uncertainty and IU. The findings suggest that uncertainty, especially about future threat, biases cognitive processes in ways that promote anxiety.
Individuals high in IU tend to overestimate the possibility and severity of threat, show heightened attention to uncertain threats, and have difficulty responding flexibly. Different dimensions of IU may confer specific vulnerabilities to certain anxiety disorders.
Examining IU can provide insight into the cognitive mechanisms underlying anxiety. Future research could further clarify the temporal dynamics of uncertainty processing, neural correlates of IU, and relationships between disorder-specific IU and symptoms.
Developing targeted interventions for high IU could potentially help prevent or alleviate impairing anxiety.
Strengths
The review systematically traced the development of IU theory and critically examined evidence from experimental studies.
It integrated findings to provide a cohesive picture of current knowledge on uncertainty and IU. Discussing both overarching constructs and disorder-specific expressions of IU allows for a nuanced understanding.
The review clearly identified remaining gaps in the literature and promising directions for future study.
Limitations
The review focused specifically on future-oriented uncertainty; other forms of uncertainty were not examined in depth.
Most of the featured research was conducted with non-clinical samples, potentially limiting generalizability to clinical populations.
Relationships between IU and other cognitive vulnerability factors were not thoroughly discussed. The neural and psychophysiological correlates of IU received minimal attention.
Implications
This review underscores the importance of considering IU in conceptualizations of anxiety disorders.
The findings suggest that IU is a maintaining factor across disorders and a potential transdiagnostic treatment target for those with GAD.
Exposure-based interventions that incorporate uncertainty may be particularly beneficial. Assessing an individual’s IU could help inform case conceptualization and treatment planning.
However, further research in clinical samples is needed to fully understand the role of IU in anxiety-related psychopathology and determine how best to address it therapeutically.
References
Primary reference
Dugas, M. J., Giguère Marchal, K., Cormier, S., Bouchard, S., Gouin, J.‐P., & Shafran, R. (2023). Pain catastrophizing and worry about health in generalized anxiety disorder. Clinical Psychology & Psychotherapy, 30(4), 852–861. https://doi.org/10.1002/cpp.2843
Other references
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders ( 5th ed.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.97808904
Constans, J. I., Barbee, J. G., Townsend, M. H., & Leffler, H. (2002). Stability of worry content in GAD patients: A descriptive study. Journal of Anxiety Disorders, 16, 311–319. https://doi.org/10.1016/S0887-6185(02)00102-0
Craske, M. G., Rapee, R. M., Jackel, L., & Barlow, D. H. (1989). Qualitative dimensions of worry in DSM-III-R generalized anxiety disorder subjects and nonanxious controls. Behaviour Research and Therapy, 27, 397–402. https://doi.org/10.1016/0005-7967(89)90010-7
Dugas, M. J., Freeston, M. H., Ladouceur, R., Rhéaume, J., Provencher, M. D., & Boisvert, J.-M. (1998). Worry themes in primary GAD, secondary GAD, and other anxiety disorders. Journal of Anxiety Disorders, 12, 253–261. https://doi.org/10.1016/S0887-6185(98)00013-9
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, 215–226. https://doi.org/10.1016/S0005-7967(97)00070-3
Hunot, V., Churchill, R., Teixeira, V., & Silva de Lima, M. (2010). Psychological therapies for generalised anxiety disorder (review). Cochrane Database of Systematic Reviews, 2007(Issue 1), Art. No. CD001848. https://doi.org/10.1002/14651858.CD001848.p
Roemer, L., & Orsillo, S. M. (2007). An open trial of acceptance-based behavior therapy for generalized anxiety disorder. Behavior Therapy, 38, 72–85. https://doi.org/10.1016/j.beth.2006.04.004
Keep Learning
Here are some potential discussion questions for a college class on this paper:
- What are some everyday examples of how uncertainty might fuel anxiety? Have you noticed this in your own life?
- How might understanding IU help us develop more effective treatments for anxiety disorders? What would an IU-focused intervention look like?
- The review suggests that disorder-specific IU may be particularly important. What other disorder-specific cognitive factors might interact with IU?
- If you were to design a study to further investigate IU, what research questions would you prioritize? What methods would you use?
