Cognitive Behaviour Therapy Vol 41, No 3, pp.

212–222, 2012

A Transdiagnostic Examination of Intolerance of

Uncertainty Across Anxiety and Depressive Disorders

Alison E. J. Mahoney1 and Peter M. McEvoy2,3

1
Clinical Research Unit for Anxiety and Depression, St Vincent’s Hospital, Sydney,
Australia; 2Centre for Clinical Interventions, Perth, Australia; 3School of Psychology,
University of Western Australia, Perth, Australia

Abstract. Intolerance of uncertainty (IU) has been identified as a potential maintaining factor for
generalised anxiety disorder; however, there is a growing evidence to suggest that IU may contribute
to other anxiety and depressive disorders. Moreover, certain components of IU (namely prospective
and inhibitory IU) have been shown to be differentially associated with symptoms of emotional
disorders. The aim of this study was to determine the extent to which individuals with various anxiety
and depressive disorders endorsed IU, firstly as a trait variable (with prospective and inhibitory
components) and secondly in reference to regularly occurring, diagnostically relevant situations
(situation-specific IU). The degree to which diagnosis predicted IU was examined in a highly
comorbid clinical sample (N ¼ 218). Regardless of specific diagnoses, the degree of comorbidity
emerged as a significant predictor of prospective IU and situation-specific IU. Conversely, specific
diagnoses of social phobia, generalised anxiety disorder, depression, and obsessive compulsive
disorder were uniquely related to inhibitory IU. These findings suggest that IU is a transdiagnostic
construct and have implications for current diagnosis-specific and transdiagnostic theory and clinical
practice. Key words: intolerance of uncertainty; transdiagnostic; anxiety; depression; cognitive
behaviour therapy

Received 2 February 2011; Accepted 18 August 2011

Correspondence address: Alison E. J. Mahoney, Clinical Research Unit for Anxiety and Depression,
St Vincent’s Hospital, Level 4 O’Brien Centre, 394-404 Victoria Street, Darlinghurst, Sydney,
New South Wales 2010, Australia. Tel: þ 612 8382 1407. Fax: þ 612 8382 1402. E-mail:
amahoney@stvincents.com.au

Introduction factor for generalised anxiety disorder (GAD);

Transdiagnostic models of anxiety disorders
emphasise the role of common factors in the
development and maintenance of pathology
(Barlow, 2000). Research has sought to identify
common vulnerability factors, such as neur-
oticism or negative affectivity (Mineka, Wat-
son, & Clark, 1998), as well as factors that serve
as specific cognitive vulnerabilities for particu-
lar anxiety disorders (e.g., anxiety sensitivity in
panic disorder; Sexton, Norton, Walker, &
Norton, 2003). Intolerance of uncertainty (IU)
has been proposed as a cognitive vulnerability
however, there is growing evidence to suggest
that IU may be an important transdiagnostic
maintaining factor (Starcevic & Berle, 2006).
The current paper seeks to explore IU across
the anxiety disorders and depression in order to
examine its relevance as a transdiagnostic
construct.
IU has been conceptualised as a cognitive
bias that leads individuals to appraise
uncertain situations as negative (Ladouceur,
Talbot, & Dugas, 1997; Koerner & Dugas,
2008). Individuals who are intolerant of

q 2012 Swedish Association for Behaviour Therapy ISSN 1650-6073

http://dx.doi.org/10.1080/16506073.2011.622130
VOL 41, NO 3, 2012
uncertainty experience the possibility of
negative future events as threatening and
unacceptable, regardless of the probability of
events actually occurring (Dugas, Gosselin, &
Ladouceur, 2001). Krohne (1993) has argued
that numerous unhelpful behaviours com-
monly seen in anxiety disorders are motivated
by a desire to reduce aversive uncertainty, for
example, reassurance seeking, hypervigilance,
or excessive checking.
IU has been associated with multiple
anxiety disorders and depression. Evidence
suggests that IU is a cognitive vulnerability
factor for worry (Sexton et al., 2003; van de
Heiden et al., 2010), and IU has also been
proposed as a maintaining factor in contem-
porary cognitive models of GAD (Behar,
DiMarco, Hekler, Mohlman, & Staples, 2009;
Dugas, Gagnon, Ladouceur, & Freeston,
1998). It has been shown to significantly
predict symptoms of GAD (Laugesen, Dugas,
& Bukowski, 2003), obsessive compulsive
disorder (OCD; Steketee, Frost, & Cohen.,
1998), social phobia (Boelen & Reijntjes, 2009;
Carleton, Collimore, & Asmundson, 2010),
depression (de Jong-Meyer, Beck, & Riede,
2009; Miranda, Fontes, & Marroquı’n, 2008),
panic disorder, and agoraphobia (McEvoy &
Mahoney, 2011). In a recent meta-analysis,
Gentes and Ruscio (2011) found robust
associations between two measures of IU
and symptoms of GAD, depression, and
OCD. Moreover, McEvoy & Mahoney (in
press) have demonstrated that different com-
ponents of IU partially mediate the
relationship between neuroticism and symp-
toms of GAD, OCD, social phobia, panic
disorder, agoraphobia, and depression. How-
ever, the meditational pathway explained a
higher proportion of variance in GAD
symptoms (i.e., worry) than symptoms of the
other disorders. IU has also been shown to
differentiate between levels of GAD severity
(Ladouceur, Blais, Freeston, & Dugas, 1998;
Dugas et al., 2007) and distinguish between
subtypes of OCD (Tolin, Abramowitz, Bri-
gidi, & Foa, 2003). Additionally, it has been
associated with treatment gains during cogni-
tive behavioural therapy for GAD (Dugas &
Ladouceur, 2000; Dugas et al., 2003), OCD
(Overton & Menzies, 2005), social phobia
(Hewitt, Egan, & Rees, 2009), and hypochon-
driasis (Langlois & Ladouceur, 2004). Thus,
IU appears to be relevant to a broad range of
Intolerance of Uncertainty 213
emotional disorders, although its the com-
parative importance for the various internali-
sing disorders requires clarification.
Previous research has sought to compare
the degree to which IU is reported in various
diagnostic groups. In an analogue sample,
Holaway, Heimberg, and Coles (2006) found
that participants with symptoms of both GAD
and OCD reported greater IU than those with
only GAD or OCD symptoms. Interestingly,
levels of IU were not significantly different for
students with only OCD or GAD symptoms.
In a community sample, Carleton et al. (2010)
reported similar findings comparing IU in
those with symptoms of GAD and/or social
phobia. Again participants with symptoms of
both disorders reported more IU than those
with symptoms of a single disorder. Levels of
IU were comparable for those with social
phobia or GAD symptoms. Steketee et al.
(1998) found that participants with OCD
reported more IU compared to a mixed
anxiety disorders group (including panic
disorder, social phobia, and GAD). Steketee
et al. (1998) did not use structured diagnostic
assessments, and comparisons across dis-
orders within the mixed anxiety group were
not made. Ladouceur et al. (1999) found that
patients with a primary or secondary diag-
nosis of GAD reported greater IU compared
to a mixed anxiety disorders group. The
numbers of participants with social anxiety,
OCD, and panic disorder varied substantially
between groups. For example, the primary
GAD group included 6 participants with
OCD, the secondary GAD group included
10 participants with OCD, whereas the mixed
anxiety disorders group consisted of 28
participants with OCD. The difference in IU
across the groups may have therefore been a
result of the specific presence of GAD or may
have reflected the groups’ overall diagnostic
composition. In a study by Dupuy and
Ladouceur (2008), GAD patients with comor-
bid major depression reported more IU
compared to non-depressed GAD patients.
Although Dupuy and Ladouceur controlled
for the number of comorbid diagnoses, the
actual type of comorbid diagnosis was not
controlled for. Therefore, drawing con-
clusions about levels of IU in specific
diagnostic groups without controlling for
comorbid diagnoses is difficult.
214 Mahoney and McEvoy
To our knowledge, two studies have
controlled for comorbid conditions by using
‘pure’ (i.e., non-comorbid) diagnostic groups.
Although these samples may not be typical of
anxious and depressed populations in general,
they do allow for clearer comparisons. Dugas,
Marchand, and Ladouceur (2005) found that
patients with GAD reported significantly
greater IU than those with panic disorder
with agoraphobia. In the second study,
participants with comorbid GAD and major
depressive disorder (MDD) reported greater
IU compared to those with either GAD or
MDD alone (Yook, Kim, Suh, & Lee, 2010).
Levels of IU were not significantly different
for those with either a diagnosis of GAD or
MDD. Although some evidence suggests
that IU may be more heavily endorsed by
those with GAD, further research is required
to clarify discrepancies and investigate
differences in IU across a variety of inter-
nalising disorders in highly comorbid clinical
samples.
Existing research has tended to examine IU
as a unitary construct; however, recent studies
suggest that certain components of IU are
differentially associated with symptoms of
internalising disorders (Carleton et al., 2010;
McEvoy & Mahoney, 2011). Carleton, Nor-
ton, and Asmundson (2007) identified two
factors within IU, namely, prospective anxiety
and inhibitory anxiety. Prospective anxiety
relates to anxiety in anticipation of uncer-
tainty, whereas inhibitory anxiety relates to
inaction in the face of uncertainty. Carleton
et al. (2010) found that inhibitory anxiety, but
not prospective anxiety, was uniquely associ-
ated with social anxiety symptoms. McEvoy
and Mahoney (2011) found that prospective
anxiety was uniquely associated with symp-
toms of GAD and OCD, whereas inhibitory
anxiety was uniquely associated with symp-
toms relating to social phobia, panic disorder,
agoraphobia, and depression. Given that IU
was related to emotions other than anxiety
(i.e., depression), McEvoy and Mahoney
(2011) suggested that prospective and inhibi-
tory anxiety be relabelled prospective and
inhibitory IU (these are the labels that will be
used in this study). This relabeling was
subsequently supported by the authors of the
IUS-12 (R. N. Carleton, personal communi-
cation, January 11, 2011). This study seeks to
extend this line of research by firstly investi-
COGNITIVE BEHAVIOUR THERAPY
gating the extent to which prospective and
inhibitory IU are endorsed across various
anxiety and depressive disorders, and secondly
by examining the relationship between comor-
bidity and prospective and inhibitory IU.
Differences across diagnostic groups have
not been examined with respect to situation-
specific IU, that is, IU that is associated with
situations that particularly distress people
with anxiety disorders (e.g., uncertainty
about the cause of physical symptoms of
anxiety for panic disorder or uncertainty
about the meaning or consequences of
intrusive thoughts for OCD). Research to
date has tended to explore trait or trans-
situational IU, for example, general beliefs
such as ‘Uncertainty makes life intolerable’ or
‘When I am uncertain I can’t function very
well’ (Buhr & Dugas, 2002). Tolin et al. (2003)
have suggested that general experiences of
uncertainty may or may not reflect how
anxious patients feel about uncertainty associ-
ated with specific situations that cause them
difficulty. Similarly, Carleton et al. (2010)
hypothesised that IU specifically in relation to
social situations may be a key factor in
determining symptoms of social phobia; they
cited the example that uncertainty is often
associated with the repetitive negative think-
ing frequently experienced before, during, and
after social situations. Mahoney and McEvoy
(2011) recently found that people with anxiety
disorders report more IU in relation to
diagnostically relevant situations compared
to IU that is generic or trait-like in nature, and
that this situation-specific IU is associated
with symptoms of GAD, OCD, social phobia,
depression, panic disorder, and agoraphobia.
There is some indication that trait IU may be
less relevant to panic disorder than other
anxiety disorders (Dugas et al., 2005);
however, we have recently shown that
situation-specific IU was predictive of symp-
toms of panic disorder and agoraphobia over
and above trait IU (Mahoney & McEvoy,
2011). Even if trait IU is less important for
some disorders than others, levels of IU may
be comparable across diagnostic groups when
examining IU specifically in relation to areas
of primary clinical concern. If this is the case,
then there may be implications for the
formulation and treatment of internalising
disorders as well as the transdiagnostic
conceptualisation of IU.
VOL 41, NO 3, 2012
The aim of this study was to examine
whether trait and situation-specific IU are
diagnosis specific or related to multiple
internalising disorders. To this end, we
examined the extent to which trait IU
(including prospective and inhibitory com-
ponents) and situation-specific IU were
endorsed by participants with various anxiety
and depressive disorders. We then evaluated
the utility of specific diagnoses (GAD, social
phobia, OCD, panic disorder with or without
agoraphobia, and depression) in predicting IU
(trait and situation specific) after taking into
account the number of diagnoses. Consistent
with a transdiagnostic conceptualisation of
IU, we predicted that IU will be elevated in
multiple diagnoses compared to a non-clinical
sample (Carleton, Norton, et al., 2007). We
also hypothesised that the number of diag-
noses or degree of comorbidity would predict
IU; with greater comorbidity associated with
higher IU. Our last hypothesis was that
multiple diagnoses would uniquely predict
IU, but that the relationship would be
strongest with GAD.
Method
Participants
Participants (N ¼ 218, 51% women) were
recruited from a specialist anxiety disorders
treatment service. This sample has been
previously employed in a separate study for
a different purpose (Mahoney & McEvoy,
2011). Participants had a mean age of 35.73
years (SD ¼ 11.59) and 73% had completed
high school. Regarding relationship status,
32% reported that they were married or in de
facto relationships, 59% were never married,
9% separated or divorced, and 1% widowed.
Prior to treatment, participants completed the
Anxiety Disorders Interview Schedule for
DSM-IV (ADIS-IV; Brown, DiNardo, &
Barlow, 1994). The principal diagnoses of the
sample included social phobia (45%), GAD
(19%), panic disorder with or without
agoraphobia (19%), OCD (7%), MDD
(5%), dysthymic disorder (1%), specific
phobia (2%), post-traumatic stress disorder
(2%), and somatisation disorder (1%). The
majority of the sample experienced comorbid
disorders; 23% of the sample met criteria for
one diagnosis, 31% with two diagnoses, 26%
with three diagnoses, 13% with four diag-
Intolerance of Uncertainty 215
noses, 6% with five diagnoses, and 1%
meeting diagnostic criteria for six diagnoses.
Comorbid diagnoses included GAD (28%),
social phobia (18%), OCD (8%), panic
disorder with or without agoraphobia (7%),
depressive disorder (40%), alcohol use dis-
order (13%), and drug use disorder (4%).
Measures
Anxiety Disorders Interview Schedule for
DSM-IV (ADIS-IV). The ADIS-IV (Brown
et al., 1994) is a structured diagnostic inter-
view for the anxiety, mood, somatoform, and
substance use disorders according to criteria
of the DSM-IV. Brown, Di Nardo, Lehman,
and Campbell (2001) provide evidence of good
inter-rater reliability for the anxiety disorders
investigated in the present study (k ¼ .65 –
.79). Inter-rater reliability (k ¼ .63) for the
combined depressive disorders group (MDD
and dysthymia) was also acceptable (Brown
et al., 2001). Evidence of construct validity,
including discriminant and convergent val-
idity, has been demonstrated (Brown, Chor-
pita Barlow, 1998).
Diagnosticians in this study were four
clinical psychologists and four psychiatric
registrars. Training involved (a) thorough
reading of the ADIS-IV protocol, (b) obser-
vation of an experienced interviewer conduct-
ing an ADIS-IV, and (c) administration of an
ADIS-IV while being observed by an experi-
enced interviewer. After the training inter-
views, diagnosticians compared and reviewed
diagnoses. All clinicians had extensive experi-
ence in the assessment and treatment of
internalising disorders. Principal diagnoses
were determined collaboratively by assessing
clinicians and participants as the most
distressing and life-interfering disorder at the
time of interview.
Intolerance of Uncertainty Scale-12 (IUS-12).
The 12-item IUS-12 (Carleton, Norton, et al.,
2007) was our trait measure of IU and consists
of two subscales: prospective IU (P-IU) and
inhibitory IU (I-IU). P-IU assesses anxiety in
anticipation of uncertainty (e.g., ‘One should
always look ahead so as to avoid surprises’),
whereas I-IU measures inhibition of action or
experience (e.g., ‘The smallest doubt can
stop me from acting’). Evidence of internal
consistency (a ¼ .91 for total score), conver-
gent validity, discriminant validity, and
factorial stability has been demonstrated
216 Mahoney and McEvoy
(Carleton, Norton, et al., 2007; McEvoy &
Mahoney, 2011). In this study, internal
consistency was good (IUS-12 total a ¼ .94,
average inter-item correlation ¼ .55; P-IU
a ¼ .91, average inter-item correlation ¼ .58;
I-IU a ¼ .88, average inter-item
correlation ¼ .59).
Intolerance of Uncertainty Scale – Situation-
Specific Version (IUS-SS). The 12-item IUS-
SS is an adaptation of the IUS-12 and was
used to index IU in relation to specific
situations that were pertinent to the sampled
anxiety disorders. When completing the IUS-
SS, participants select their area of primary
concern from a list (e.g., social interactions or
performance situations, places or situations
that may lead to panic sensations, excessive
worries about everyday concerns, intrusive
distressing thoughts that lead to repetitive
behaviours) and then describe a situation
related to this concern that was regularly
occurring and distressing (e.g., conversations
with a colleague, catching trains, watching the
evening news, touching door knobs). The
items from the IUS-12 were then completed in
reference to that situation (item wording was
altered to reference the situation, e.g., the IUS-
12 item ‘I can’t stand being taken by surprise’
became ‘I can’t stand being taken by surprise
in this situation’). The measure has a unitary
factor structure and excellent internal consist-
ency (a ¼ .94, average inter-item
correlation ¼ .55; Mahoney & McEvoy,
2011). Evidence of convergent and divergent
validity has been demonstrated via expected
relationships with measures of trait IU,
personality dimensions, alcohol use, and
symptoms of anxiety and depressive disorders
(Mahoney & McEvoy, 2011).
Procedure
Participants completed the ADIS-IV, IUS-12,
and IUS-SS prior to treatment at a specialist
anxiety disorders clinic. They consented for
their data to be used for research purposes.
The use of the data was approved by the
Hospital’s Human Research Ethics Commit-
tee.
Results
Situations Reported in the IUS-SS
A total of 187 participants completed the IUS-
SS; 159 described a situation that matched
COGNITIVE BEHAVIOUR THERAPY
their principal diagnosis and 20 described a
situation that matched a comorbid diagnosis.
A match was defined as a situation or
experience that appeared or was likely to
appear as an item on a relevant symptom
measure (e.g., ‘mixing in a group’ from the
Social Interaction Phobia Scale; Carleton
et al., 2009). When the relevance of situations
was unclear, qualitative data from partici-
pants’ ADIS-IV responses were consulted. A
small number of participants (n ¼ 5) did not
complete a description, and three participants
described recent financial or
relationship stressors that were unrelated to
their diagnoses. Situations were coded by one
researcher (AM), although a subsample
(n ¼ 106) was coded by an additional clinical
psychologist as a measure of reliability.
Agreement between coders was good
(k ¼ .64) and discrepancies were resolved via
discussion and consensus. Participants who
completed the IUS-SS were not significantly
different from non-completers with respect to
age, gender, number of diagnoses, or IUS-12
total score (all ps . .05).
Trait and situation-specific IU across
principal diagnosis
Table 1 shows IU means for participants
grouped by principal diagnosis. Note that due
to small sample sizes and resultant power
limitations, participants with a principal
diagnosis of MDD or dysthymic disorder
were merged into one depression group. First,
differences in trait IU across principal
diagnoses were explored. Because there were
large differences in sample sizes across
principal diagnoses, group comparisons were
limited to those with social phobia, GAD, and
panic disorder with/without agoraphobia. A
one-way ANOVA, with post hoc Bonferroni-
corrected pairwise comparisons, was used to
examine group differences. There were no
significant differences across groups for the
IUS-12 total [F (2, 159) ¼ 2.19, p ¼ .12,
h 2 ¼ .03] or P-IU [F (2, 159) ¼ 1.35, p ¼ .26,
h 2 ¼ .02]. Group differences were marginally
significant for the I-IU [F (2, 159) ¼ 3.04,
p ¼ .05, h 2 ¼ .04], with participants with
social phobia reporting slightly greater inhibi-
tory IU than participants with panic disorder
with/without agoraphobia ( p ¼ .05). Second,
differences in situation-specific IU across
VOL 41, NO 3, 2012 Intolerance of Uncertainty 217

Table 1. Mean trait and situation-specific IU across principal diagnoses

IUS-SS mean (SD) IUS-12 means (SD)

Principal diagnosis N Total N Total P-IU I-IU

Social phobia 80 39.71 (11.30) 83 36.84 (11.51) 21.17 (7.12) 15.67 (5.16)
GAD 36 38.64 (9.97) 41 35.12 (11.66) 20.59 (7.04) 14.54 (5.32)
Panic þ /2 Ag 22 38.09 (15.83) 38 31.97 (12.90) 18.84 (7.75) 13.13 (5.68)
OCD 9 39.33 (12.17) 15 30.53 (11.24) 17.40 (7.51) 13.13 (4.34)
Depression 8 34.25 (9.05) 11 27.63 (14.33) 15.45 (8.50) 12.18 (6.42)
Note. IUS-12, Intolerance of Uncertainty Scale-12; IUS-SS, Intolerance of Uncertainty Scale – Situation-
Specific version; P-IU, prospective IU; I-IU, inhibitory IU; GAD, generalised anxiety disorder; Panic þ /2 Ag,
panic disorder with or without agoraphobia; OCD, obsessive compulsive disorder; depression, major depressive
disorder or dysthymic disorder.

principal diagnosis were examined. Situation-
specific IU analyses were restricted to those
with primary social phobia, GAD, and panic
disorder (with/without agoraphobia) and had
completed the IUS-SS in reference to a
situation that matched their principal diag-
nosis. The assumption of homogeneity of
variances was violated for this one-way
ANOVA, and as such, the Brown-Forsythe
test was employed. There were no significant
differences across principal diagnoses for the
IUS-SS total [F (2, 49.54) ¼ .18, p ¼ .84,
h 2 ¼ .003].
Trait and situation-specific IU across
internalising disorders
Bivariate Pearson correlation coefficients
suggested that there were significant corre-
lations between the number of diagnoses and
the IUS-12 [r ¼ .31, p , .001], prospective IU
[r ¼ .28, p , .001], inhibitory IU [r ¼ .31,
p , .001], and the IUS-SS [r ¼ .30, p , .001].
Table 2 shows IU means across the anxiety
and depressive disorders (means correspond to
present diagnoses whether the diagnosis was
principal or additional). The trait IU means
for each diagnostic group were compared to
the IUS-12 means previously reported in a
student sample (N ¼ 818, IUS-12 total
M ¼ 25.85, SD ¼ 9.45; Carleton, Norton,
et al., 2007). We examined differences between
the current IUS-12 total mean score and the
student IUS-12 total mean score using Welch’s
t test (with Bonferroni corrections). Current
trait IU was significantly greater than the
student trait IU for all diagnoses including
social phobia [t(141) ¼ 9.87, p , .001,
h 2 ¼ .41], GAD [t(107) ¼ 9.06, p , .001,
h 2 ¼ .43], panic disorder with/without agor-
aphobia [t(57) ¼ 3.65, p , .001, h 2 ¼ .19],
OCD [t(33) ¼ 4.14, p , .001, h 2 ¼ .34], and
depression [t(101) ¼ 8.54, p , .001, h 2 ¼ .42].
Mean IUS-SS scores were not available for the
student sample and so no comparisons were
made between student and clinical means.

Table 2. Mean trait and situation-specific IU across anxiety and depressive disorders

IUS-SS mean (SD) IUS-12 means (SD)

Diagnosis N Total N Total P-IU I-IU

Social phobia 119 39.87 (11.73) 119 36.97 (11.75) 21.34 (7.26) 15.64 (5.16)
GAD 89 40.96 (10.23) 93 36.75 (11.15) 21.37 (6.95) 15.39 (4.97)
Panic þ /- Ag 44 39.93 (15.09) 55 33.07 (14.48) 19.29 (8.72) 13.78 (6.19)
OCD 29 38.76 (12.18) 33 35.21 (12.86) 20.27 (8.35) 14.94 (5.07)
Depression 86 42.16 (12.52) 91 37.48 (12.60) 21.46 (7.59) 12.18 (6.42)
Note. IUS-12, Intolerance of Uncertainty Scale-12; IUS-SS, Intolerance of Uncertainty Scale – Situation-
Specific version; P-IU, Prospective IU; I-IU, Inhibitory IU; GAD, generalised anxiety disorder; Panic þ /2 Ag,
panic disorder with or without agoraphobia; OCD ¼ obsessive compulsive disorder; Depression, major depressive
disorder or dysthymic disorder.
218 Mahoney and McEvoy
Internalising disorders as predictors of
trait and situation-specific IU
In order to take account of comorbidity, the
presence or absence of each diagnosis of
interest in this study was dummy coded for use
as predictors. Controlling for the degree of
comorbidity, the predictive utility of specific
diagnoses was then examined with respect to
trait and situation-specific IU. Three hier-
archical multiple linear regression analyses
were conducted with the number of diagnoses
entered in step 1 and the five dummy-coded
diagnostic variables entered as step 2. Cri-
terion variables were P-IU, I-IU, and IUS-SS.
At step 1, the number of diagnoses signifi-
cantly predicted P-IU [DR 2 ¼ .08, b ¼ .28,
t(197) ¼ 4.06, p , .001] and IUS-SS
[DR 2 ¼ .08, b ¼ .29, t(177) ¼ 4.00, p , .001].
Adding specific diagnoses in step 2 failed to
explain a significant proportion of additional
variance in P-IU [DR 2 ¼ .03, F (5,
192) ¼ 1.46, p ¼ .21] or in IUS-SS
[DR 2 ¼ .01, F (5, 172) ¼ .28, p ¼ .93]. Results
for I-IU were different. As seen in Table 3, the
number of diagnoses significantly predicted I-
IU at step 1. At step 2, however, specific
diagnoses explained a significant proportion
of variance in I-IU, whereas the number of
diagnoses did not. All diagnoses, except panic
disorder with/without agoraphobia, explained
a significant portion of variance in I-IU (see
Table 3). Note that data for the regression
involving the IUS-SS as the criterion variable
were restricted to participants who described
situations consistent with their principal or
additional diagnoses (n ¼ 179). For these
regressions, variance inflation factors (1.00–
Table 3. Summary of Hierarchical Linear Regressions for Diagnoses Predicting I-IU
Criterion Predictors
I-IU Step 1: Number of diagnoses
Step 2: Number of diagnoses
Social Phobia
GAD Panic
disorder þ/2 Ag
OCD
Depression
Note. I-IU, Inhibitory Intolerance of Uncertainty; GAD, generalised anxiety disorder; Panic þ/2 Ag, panic
disorder with or without agoraphobia; OCD, obsessive compulsive disorder; Depression, major depressive disorder
and/or dysthymic disorder.
*p ¼ .55. **p , .05. ***p , .001.
COGNITIVE BEHAVIOUR THERAPY
3.06) did not suggest problematic collinearity
(O’Brien, 2007).
Discussion
IU has been associated with a broad array of
symptoms of emotional disorders (Gentes &
Ruscio, 2011; McEvoy & Mahoney, 2011).
Previous research has explored the relative
importance of IU to specific anxiety and
depressive disorders by comparing the degree
to which IU is reported by various diagnostic
groups. The current study extends this line of
investigation by examining the extent to which
IU is endorsed firstly as a trait variable and
secondly in reference to regularly occurring,
diagnostically relevant situations in a highly
comorbid clinical sample.
Our first hypothesis was that IU would be
elevated in multiple diagnoses relative to a
non-clinical population. The trait IU means
for participants with diagnoses of social
phobia, GAD, panic disorder and agorapho-
bia, OCD, and/or depression found in this
study were greater than the trait IU means
previously found in student samples (Carleton
et al., 2007). Levels of trait IU were
comparable across principal diagnosis to a
large extent. Specifically, there were no
significant differences in total trait IU score
or the prospective IU component across
participants with a principal diagnosis of
GAD, social phobia, or panic disorder with/-
without agoraphobia. These results are con-
sistent with Carleton et al.’s (2010) study,
which found that levels of trait IU were
comparable in those experiencing symptoms
of GAD or social phobia. However, our
DR 2 B t Part r
.09*** 1.36 4.33*** .30
.07** 2.12 2 .23 2.02
3.37 3.31*** .22
1.96 2.11** .14
1.09 1.07 .07
2.18 1.93* .13
2.60 2.48** .17
VOL 41, NO 3, 2012
findings are not consistent with Dugas et al.
(2005) and Ladouceur et al. (1999) who
reported greater IU in GAD compared to
other anxiety disorders. Discrepancies may
relate to differences in methods and samples
across studies; the current sample was highly
comorbid, whereas Dugas et al.’s (2005)
sample comprised participants with non-
comorbid GAD or panic disorder and
Ladouceur et al.’s (1999) sample compared
individuals with GAD to a mixed anxiety
disorders group. Comparisons between trait
IU for those with principal social phobia or
panic disorder have not been previously
reported. Our results suggest that levels of
IU are similar across these primary diagnoses,
although levels of inhibitory IU were margin-
ally greater for those with principal social
phobia compared to those with principal panic
disorder with/without agoraphobia. These
differences were modest and may not be
clinically significant. This study extended
previous research by exploring the relative
endorsement of situation-specific IU across
diagnostic groups. There were no significant
differences in IU scores when participants
with principal social phobia, GAD, or panic
disorder reported IU in reference to a
regularly occurring, distressing situation that
related to their primary area of concern.
Unfortunately, sample size restrictions pre-
cluded comparisons across primary OCD and
depression, and this remains an avenue for
additional investigation. Nevertheless, IU was
endorsed to a similar degree across three
primary anxiety disorders and these results
support the transdiagnostic conceptualisation
of IU.
The second aim of this study was to examine
IU across comorbid conditions. We hypoth-
esised that the number of diagnoses or degree
of comorbidity would predict IU. This
hypothesis was supported; we found that the
number of diagnoses was positively correlated
with trait and situation-specific IU. This is
consistent with previous research that has
found higher levels of IU in those with
multiple diagnoses versus a single diagnosis
(Dupuy & Ladouceur, 2008; Yook et al.,
2010). However, contrary to predictions, no
specific diagnosis (principal or additional) was
a significant predictor of P-IU or situation-
specific IU once the degree of comorbidity was
taken into account. This suggests that
Intolerance of Uncertainty 219
prospective IU and situation-specific IU did
not substantially vary across the sampled
internalising disorders.
Conversely, multiple diagnoses predicted
unique variance in inhibitory IU, specifically
social phobia, GAD, depressive disorders, and
OCD (marginally). This suggests that each of
these disorders is related to avoidance and
inaction in anticipation of uncertainty. Inhibi-
tory IU also encompasses beliefs that uncer-
tainty leads to reduced functional capacity
and prevents individuals from living a full life.
Our findings are consistent with research that
has linked I-IU with social phobia and
depression symptoms (Carleton et al., 2010;
McEvoy & Mahoney, 2011). However, our
results seem somewhat inconsistent with
previous findings that symptoms of panic
disorder are uniquely associated with I-IU,
while symptoms of GAD (namely worry) are
uniquely associated with prospective IU
(McEvoy & Mahoney, 2011). Although the
reasons for this are not entirely clear, the
inhibitory component of IU is potentially
more likely to be a feature of diagnoses, rather
than the continuum of symptoms because
individuals are more likely to be inhibited and
functionally impaired when their symptoms
are more severe and constitute a disorder. The
association between I-IU and panic symptoms
may also be a consequence of confounding by
symptoms of comorbid disorders. The
relationship between IU and panic disorder
may be complex and influenced by other
factors, such as anxiety sensitivity. Individuals
with high anxiety sensitivity tend to fear
anxiety-related symptoms (e.g., bodily sen-
sations and thoughts) because they appraise
these symptoms as dangerous and harmful
(Taylor, Koch, & McNally, 1992). Anxiety
sensitivity and trait IU are inter-related but
independent factors (Carleton, Sharpe, &
Asmundson, 2007), and both have been
associated with symptoms of panic disorder
(McEvoy & Mahoney, 2011; Taylor et al.,
1992). Interestingly, Sexton et al. (2003) found
that trait IU was not directly associated with
symptoms of panic disorder in a model that
included both trait IU and anxiety sensitivity.
Future research examining relationships
between emotional disorders, IU, and other
disorder-specific and transdiagnostic con-
structs would be informative for theory and
treatment development. Our current results do
220 Mahoney and McEvoy
not support the contention that IU is specific
to one diagnostic group, and rather suggest
that IU is associated with multiple anxiety
disorders and depression.
There are a number of theoretical and
clinical implications to consider. The current
findings are consistent with the Intolerance of
Uncertainty Model of GAD (Dugas, Letarte,
Rhéaume, Freeston, & Ladouceur, 1995;
Dugas et al., 1998) and GAD treatments that
target IU (such as Dugas et al., 2010). Our
findings also encourage researchers to examine
the relevance of IU firstly with respect to
existing cognitive models for the other anxiety
disorders and depression, and secondly in
relation to current transdiagnostic conceptu-
alisations of emotional disorders. The finding
that IU is elevated across the anxiety disorders
and depression does not signify that IU
contributes to the development or mainten-
ance of these disorders. Future studies are
required to demonstrate the casual and
cyclical relationships between IU and symp-
toms of emotional disorders. Additionally,
future studies need to examine how IU
interacts with other constructs thought to
perpetuate anxiety and depressive disorders.
Although there is evidence to suggest that IU
partially mediates the relationship between
neuroticism and symptoms of anxiety and
depression (McEvoy & Mahoney in press),
studies are required to establish how IU
interacts with other important constructs such
as repetitive negative thinking, behavioural
avoidance, and metacognitive beliefs. Clarify-
ing the nature of these interactions will guide
the development of treatments, which can
address the processes most responsible for
symptoms of psychopathology. Existing cog-
nitive behaviour therapies may be augmented
by targeting IU-related fears and avoidance
behaviours. The efficacy of such treatment
enhancements, or of transdiagnostic protocols
targeting multiple common mechanisms
including IU, is yet to be established.
There are several methodical limitations of
this study that restrict our conclusions. First,
no reliability data were available for ADIS-IV
diagnoses. Second, the study utilised self-
report data, which may have resulted in
difficulties with shared method variance and
subjective reporting of IU. Additionally, no
behavioural measures were employed to
corroborate the self-report measures, and the
COGNITIVE BEHAVIOUR THERAPY
lack of longitudinal data precludes con-
clusions regarding the relationships between
IU and internalising disorders over time.
Lastly, the number of participants in the
current study with principal diagnoses of
OCD, specific phobia, posttraumatic stress
disorder, or depressive disorder was small.
This limits the generalisability of our results
and restricts conclusions regarding the nature
of IU in these disorders. Future research may
seek to address these shortcomings.
Notwithstanding these limitations, this
study found evidence to suggest that both
trait and situation-specific IU are endorsed to
a similar degree across the anxiety disorders
and depression. IU is related to multiple
diagnoses and increases with escalating
comorbidity. This study supports the trans-
diagnostic conceptualisation of IU and
encourages further development and explora-
tion of transdiagnostic treatment approaches.
References
Barlow, D. H. (2000). Unravelling the mysteries of
anxiety and its disorders from the perspective of
emotion theory. American Psychologist, 55,
1247– 1263.
Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman,
J., & Staples, A. M. (2009). Current theoretical
models of generalised anxiety disorder (GAD):
Conceptual review and treatment implications.
Journal of Anxiety Disorders, 23, 1011– 1023.
Boelen, P. A., & Reijntjes, A. (2009). Intolerance of
uncertainty and social anxiety. Journal of
Anxiety Disorders, 29, 130– 135.
Brown, T. A., Chorpita, B. F., & Barlow, D. H.
(1998). Structural relationships among dimen-
sions of the DSM-IV anxiety and mood
disorders and dimensions of negative affect,
positive affect, and autonomic arousal. Journal
of Abnormal Psychology, 107, 179– 192.
Brown, T. A., DiNardo, P. A., & Barlow, D. H.
(1994). Anxiety disorders interview schedule for
DSM-IV. Albany, NY: Graywind Publications.
Brown, T. A., DiNardo, P. A., Lehman, C. L., &
Campbell, L. A. (2001). Reliability of DSM-IV
anxiety and mood disorders: Implications for
classification of emotional disorders. Journal of
Abnormal Psychology, 110, 49 – 58.
Buhr, K., & Dugas, M. J. (2002). The Intolerance of
Uncertainty Scale: Psychometric properties of
the English version. Behaviour Research and
Therapy, 40, 931– 945.
Carleton, R. N., Collimore, K. C., & Asmundson,
G. (2010). “It’s not just the judgments—It’s that
I don’t know”: Intolerance of uncertainty as a
predictor of social anxiety. Journal of Anxiety
Disorders, 24, 189– 195.
VOL 41, NO 3, 2012
Carleton, R. N., Collimore, K. C., Asmundson, G. J.
G., McCabe, R. E., Rowa, K., & Antony, M. M.
(2009). Refining and validating the Social
Interaction Anxiety Scale and the Social Phobia
Scale. Depression and Anxiety, 26, E71– E81.
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, 105– 117.
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,
2307– 2316.
de Jong-Meyer, R., Beck, B., & Riede, K. (2009).
Relationships between. Personality and Individ-
ual Differences, 46, 547– 551.
Dugas, M. J., Brillon, P., Savard, P., Turcotte, J.,
Gaudet, A., Ladouceur, R., . . . Gervais, N. J.
(2010). A randomized clinical trial of cognitive-
behavioral therapy and applied relaxation for
adults with generalized anxiety disorder. Beha-
vior Therapy, 41, 46 – 58.
Dugas, M. J., Gagnon, F., Ladouceur, R., &
Freeston, M. H. (1998). Generalised anxiety
disorder: A preliminary test of a conceptual
model. Behaviour Research and Therapy, 36,
215– 226.
Dugas, M. J., Gosselin, P., and Ladouceur, R.
(2001). Intolerance of uncertainty and worry:
Investigating specificity in a nonclinical sample.
Cognitive Therapy and Research, 25, 551– 558.
Dugas, M. J., & Ladouceur, R. (2000). Treatment
of GAD: Targeting intolerance of uncertainty in
two types of worry. Behavior Modification, 24,
635– 657.
Dugas, M. J., Ladouceur, R., Léger, E., Freeston,
M. H., Langlois, F., Provencher, M., &
Boisvert, J. M. (2003). Group cognitive beha-
vioral therapy for generalised anxiety disorder:
Treatment outcome and long-term follow-up.
Journal of Consulting and Clinical Psychology,
71, 821– 825.
Dugas, M. J., Letarte, H., Rhéaume, J., Freeston,
M. H., & Ladouceur, R. (1995). Worry and
problem solving: Evidence of a specific relation-
ship. Cognitive Therapy and Research, 19,
109– 120.
Dugas, M. J., Marchand, A., & Ladouceur, R.
(2005). Further validation of a cognitive-
behavioural model of generalised anxiety
disorder: Diagnostic and symptom specificity.
Journal of Anxiety Disorders, 19, 329 –343.
Dugas, M. J., Savard, P., Gaudet, A., Turcotte, J.,
Laugesen, N., Robichaud, M., . . . Koerner, N.
(2007). Can the components of a cognitive
model predict the severity of generalised anxiety
disorder? Behavior Therapy, 38, 169– 178.
Dupuy, J. -B., & Ladouceur, R. (2008). Cognitive
processes of generalised anxiety disorder in
comorbid generalised anxiety disorder and
major depressive disorder. Journal of Anxiety
Disorders, 22, 505 –514.
Gentes, E. L., & Ruscio, A. M. (2011). A meta-
analysis of the relation of intolerance of
Intolerance of Uncertainty 221
uncertainty to symptoms of generalized anxiety
disorder, major depressive disorder, and obses-
sive compulsive disorder. Clinical Psychology
Review, 31, 923– 933.
Hewitt, S. N., Egan, S., & Rees, C. (2009).
Preliminary investigation of intolerance of
uncertainty treatment for anxiety disorders.
Clinical Psychologist, 13, 52 – 58.
Holaway, R. M., Heimberg, R. G., & Coles, M. E.
(2006). A comparison of intolerance of uncer-
tainty in analogue obsessive-compulsive dis-
order and generalised anxiety disorder. Journal
of Anxiety Disorders, 20, 158– 174.
Koerner, N., & Dugas, M. J. (2008). An
investigation of appraisals in individuals vul-
nerable to excessive worry: The role of
intolerance of uncertainty. Cognitive Therapy
and Research, 32, 619– 638.
Krohne, H. W. (1993). Vigilance and cognitive
avoidance as concepts in coping research. In
H. W. Krohne (Ed.), Attention and avoidance:
Strategies in coping with aversiveness
(pp. 19 – 50). Seattle, WA: Hogrefe and Huber.
Ladouceur, R., Blais, F., Freeston, M. H., &
Dugas, M. J. (1998). Problem solving and
problem orientation in generalised anxiety
disorder. Journal of Anxiety Disorders, 12,
139– 152.
Ladouceur, R., Dugas, M. J., Freeston, M. H.,
Rheaume, J., Blais, F., Boisvert, J., . . .
Thibodeau, N. (1999). Specificity of generalized
anxiety disorder symptoms and processes.
Behavior Therapy, 30, 191– 207.
Ladouceur, R., Talbot, F., & Dugas, M. J. (1997).
Behavioral expressions of intolerance of uncer-
tainty in worry: Experimental findings. Behavior
Modification, 21, 355–371.
Langlois, F., & Ladouceur, R. (2004). Adaptation of
a GAD treatment for hypochondriasis. Cogni-
tive and Behavioural Practice, 11, 393– 404.
Laugesen, N., Dugas, M. J., & Bukowski, W. M.
(2003). Understanding adolescent worry: The
application of a cognitive model. Journal of
Abnormal Child Psychology, 31, 55– 64.
Mahoney, A. E. J., & McEvoy, P. M. (2011). Trait
versus situation-specific intolerance of uncer-
tainty in a clinical sample with anxiety and
depressive disorders. Manuscript submitted for
publication.
McEvoy, P. M., & Mahoney, A. E. J. (2011).
Achieving certainty about the structure of
intolerance of uncertainty in a treatment-
seeking sample with anxiety and depression.
Journal of Anxiety Disorders, 25, 112– 122.
McEvoy, P. M., & Mahoney, A. E. J. (in press). To
be sure, to be sure: Intolerance of uncertainty
mediates symptoms of various anxiety and
depressive disorders. Behavior Therapy.
Mineka, S., Watson, D., & Clark, L. A. (1998).
Comorbidity of anxiety and unipolar mood
disorders. Annual Review of Psychology, 49,
377– 412.
Miranda, R., Fontes, M., & Marroquı’n, B. (2008).
Cognitive content-specificity in future expec-
tancies: Role of hopelessness and intolerance of
222 Mahoney and McEvoy
uncertainty in depression and GAD symptoms.
Behaviour Research and Therapy, 46,
1151–1159.
O’Brien, R. M. (2007). A caution regarding rules of
thumb for variance inflation factors. Quality
and Quantity, 41, 673– 690.
Overton, S. M., & Menzies, R. G. (2005). Cognitive
change during treatment of compulsive check-
ing. Behaviour Change, 22, 172– 184.
Sexton, K. A., Norton, P. J., Walker, J. R., &
Norton, G. R. (2003). A hierarchical model of
generalised and specific vulnerabilities in
anxiety. Cognitive Behaviour Therapy, 32,
82– 94.
Starcevic, V., & Berle, D. (2006). Cognitive
specificity of anxiety disorders: A review of
selected key constructs. Depression and Anxiety,
23, 51 – 61.
Steketee, G., Frost, R. O., & Cohen, I. (1998).
Beliefs in obsessive-compulsive disorder. Jour-
nal of Anxiety Disorders, 12, 525– 537.
COGNITIVE BEHAVIOUR THERAPY
Taylor, S., Koch, W. J., & McNally, R. J. (1992).
How does anxiety sensitivity vary across the
anxiety disorders? Journal of Anxiety Disorders,
6, 249– 259.
Tolin, D., Abramowitz, J. S., Brigidi, B. D., & Foa,
E. B. (2003). Intolerance of uncertainty in
obsessive-compulsive disorder. Journal of
Anxiety Disorders, 17, 233– 242.
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
generalised anxiety disorder. Journal of Anxiety
Disorders, 24, 284– 280.
Yook, K., Kim, K., Suh, S. Y., & Lee, K. S. (2010).
Intolerance of uncertainty, worry, and rumina-
tion in major depressive disorder and general-
ised anxiety disorder. Journal of Anxiety
Disorders, 24, 623– 628.
Copyright of Cognitive Behaviour Therapy is the property of Routledge and its content may not be copied or
emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.