Intolerance of uncertainty fuels depressive symptoms through rumination: Cross-sectional and longitudinal studies

Psychological mechanisms underpinning change in intolerance of uncertainty across anxiety-related disorders: New insights for translational research

Intolerance of uncertainty (IU), the tendency to find uncertainty negative, is a fundamental transdiagnostic dimension across anxiety-related disorders. Over the past two decades, there has been an increase in both clinical and experimental research on the role of IU in the maintenance and treatment of anxiety-related disorders. However, there has been a lack of integration of research findings from a mechanistic perspective, which has slowed progress in translational research. This review seeks to fill this gap by synthesising the clinical (e.g. randomised controlled trials) and experimental (e.g. lab-based) literature on the psychological mechanisms that drive change in IU across anxiety-related disorders. The review highlighted that: (1) cognitive restructuring, supported by mechanisms such as cognitive appraisal, modify IU-related cognitions, (2) behavioural exposures, supported by mechanisms such as inhibitory learning, alter IU-related cognitions and physiological arousal, and (3) mindfulness techniques underpinned by mechanisms such as attentional monitoring, decentering, and acceptance, change IU-related cognitions. Across the different therapeutic techniques reviewed, there was a lack of evidence for how different mechanisms change IU-related emotions and behaviours. Directions for further research include directly comparing the effectiveness of different mechanisms that produce change in IU across anxiety disorders and other mental health disorders, and examining the specificity of change in IU over other anxious traits. Overall, the findings provide a foundation for future translational research efforts to build upon maximising existing treatment interventions and/or to develop novel treatment interventions to target dispositional IU and situational uncertainty-related distress in anxiety-related disorders and beyond.

Depressive symptoms, sleep-wake features, and insomnia among female students: The role of rumination

Depression symptoms are prevalent among nursing students, especially those in Asia. This study assessed the association between rumination and depression symptoms among female nursing students (N = 148) and the chain mediation role of sleep-wake indexes and insomnia symptoms. The data were collected from a battery of questionnaires and consecutive 7-day actigraphy data for analyzing sleep-wake indexes. About 54.1% of the participants had either mild or moderate depression symptoms. Most students (89.2%) had a delayed circadian phase, and circadian activity rhythm (CAR) was not ideal. The path mediation model underwent analysis using the PROCESS macros. The results showed that rumination in students is directly positively correlated with depressive symptoms (b = 4.831). Moreover, the association between rumination and depressive symptoms is sequent (moderating effect = 0.12, 95% CI [0.017, 0.410]). The proposed model in this study provides a foundation for improving educational programs on sleep hygiene and promoting mental wellness.

The Mediating Role of Fear of Happiness in the Relationship Between Rumination and Depression in University Students

In this study, the mediating role of fear of happiness in the relationship between depression levels and rumination levels of university students was examined. The dependent variable of this study is depression, the mediating variable is fear of happiness and the independent variable is rumination. The research was conducted using the relational survey method. The sample consisted of university students studying at Selçuk University in the 2021-2022 and 2022-2023 academic year. Of the participants, 83.8% (290) were female and 16.2% (56) were male. In the study, bootstrapping method was used to test the significance of the indirect effect. It was observed that fear of happiness had a partial mediating role between depression and rumination levels in university students. From this point of view, it can be said that rumination and fear of happiness will increase depression in university students. At the same time, it can be said that rumination affects depression.

Emotion regulation mediates the relation between intolerance of uncertainty and emotion difficulties: A longitudinal investigation

Intolerance of uncertainty has been proposed as a transdiagnostic factor in emotional disorders. Despite comprehensive empirical evidence demonstrating the association between intolerance of uncertainty and emotional disorders, the underlying mechanism remains elusive. Drawing on theoretical frameworks and empirical studies, the current study proposed that emotion regulation emerges as a potential mechanism. We explored the connections among intolerance of uncertainty, eight emotion regulation strategies (both adaptive and maladaptive), and emotional difficulties (specifically anxiety and depression) using a three-wave longitudinal approach (N = 341). Our findings revealed that heightened intolerance of uncertainty predicted increased anxiety but not depression over time. Greater intolerance of uncertainty significantly predicted elevated levels of maladaptive emotion regulation strategies including experiential avoidance, thought suppression, rumination, and reassurance-seeking. Adaptive strategies (i.e., mindfulness, cognitive reappraisal, problem-solving) predicted lower anxiety and/or depression whereas maladaptive emotion regulation strategy rumination predicted greater levels of anxiety and depression. Surprisingly, thought suppression predicted lower levels of anxiety and depression. More importantly, our analysis showed that both rumination and thought suppression served as significant mediators in the relationship between intolerance of uncertainty and both anxiety and depression. These results hold implications for future interventions, emphasising rumination and thought suppression as potential targets for interventions aimed at alleviating emotional difficulties in individuals with intolerance of uncertainty.

Intolerance of uncertainty on distress and impairment: The mediating role of repetitive negative thinking

Repetitive negative thinking and intolerance of uncertainty are risk and maintenance factors for emotional disorders. Although emerging evidence suggests that intolerance of uncertainty predicts increases in distress through repetitive negative thinking, these relationships have yet to be investigated among veterans. The present study examines if repetitive negative thinking mediates the relationships of intolerance of uncertainty with stress, disordered symptoms and impairment among a mixed clinical sample of veterans. Two hundred and forty-four treatment-seeking veterans with diagnoses of major depressive disorder, panic disorder, or posttraumatic stress disorder completed measures of intolerance of uncertainty, repetitive negative thinking, stress, impairment, depression, panic, and posttraumatic stress prior to receiving treatment. Mediation models revealed indirect effects of intolerance of uncertainty through repetitive negative thinking on stress and impairment in the full sample, and on disordered symptoms in subsamples with major depressive disorder and posttraumatic stress disorder. Conversely, intolerance of uncertainty did not have direct or indirect effects on disordered symptoms in a panic disorder subsample. Findings suggest that repetitive negative thinking and intolerance of uncertainty uniquely contribute to stress, impairment, and disordered symptoms, but repetitive negative thinking, may, in part, drive intolerance of uncertainty's contribution to emotional disorders. Interventions for repetitive negative thinking might improve the efficacy of existing transdiagnostic treatment protocols. Cross-sectional data is a limitation of the present study. Prospective designs in civilian samples can better establish the temporality of these relationships and if they are generalizable to the larger population.

The association between intolerance of uncertainty and depressive symptoms during COVID-19 in New York, USA

BACKGROUND

Coronavirus Disease 2019 (COVID-19), a highly contagious respiratory illnesses, has globally impacted mental health. This study aims to investigate the association between intolerance of uncertainty and depressive symptoms during the pandemic in New York, USA, considering COVID-19-related worries as modifiers and mediators.

METHOD

1227 participants from three ongoing cohort studies, originally centered on trauma-exposed children and adolescents, provided data via questionnaires and telephone interviews across three waves. We used multivariable logistic and linear regression models to investigate the intolerance of uncertainty-depressive symptoms relationship, while adjusting for potential confounders and assessing the modification and mediation effects of Covid-19 related worries.

RESULTS

Depressive symptoms prevalence was 18 %, 12 %, and 9 % at waves 0, 1, and 2 respectively. Strong positive associations were observed between intolerance of uncertainty above the median and depressive symptoms which remained significant after adjusting for potential confounders. Odds ratios were 2.14 (95 % CI: 1.54-2.99) and 4.50 (95 % CI: 2.67-7.93) for intolerance of uncertainty-depressive symptoms association at wave 0 and 1 respectively, and 3.22 (95 % CI: 1.68-6.63) for intolerance of uncertainty at wave 1 and depressive symptoms at wave 2. There was evidence of partial mediation by worries (12-37 %), but no evidence of a moderating effect.

LIMITATION

It includes study's methodology, including self-report measures, remote data collection, and uncontrolled variables like anxiety and COVID-19 perspectives.

CONCLUSION

The findings emphasize the importance of evidence-based strategies for tackling intolerance of uncertainty during pandemics, particularly in managing long COVID. Collaborative efforts between policymakers and clinicians are essential in this endeavor.

Is everything really okay?: Using ecological momentary assessment to evaluate daily co-fluctuations in anxiety and reassurance seeking

OBJECTIVE

Reassurance seeking, a behavior prominent in anxiety disorders and depression, is associated with poorer quality of interpersonal relationships and acts as a mechanism of stress generation. However, little research has elucidated momentary associations between state anxiety and reassurance seeking behaviors.

METHOD

In a sample of 104 university-affiliated young adults, we sought to replicate cross-sectional associations of reassurance seeking with trait anxiety (Aim 1) and intolerance of uncertainty (Aim 2). We then used ecological momentary assessment (EMA) to evaluate concurrent fluctuations in daily anxiety and reassurance seeking across 14 consecutive days (Aim 3). Hierarchical multi-level models for intensive longitudinal data were used to evaluate the relationship between state anxiety and daily reassurance seeking.

RESULTS

In baseline analyses, trait anxiety and intolerance of uncertainty were significantly associated with greater trait reassurance seeking, controlling for depression. Analyses of the EMA data showed that daily reassurance seeking behaviors fluctuated concurrently with daily anxiety during the 14 days, while controlling for trait anxiety and depression.

CONCLUSION

Given evidence of concurrent fluctuations between state anxiety and reassurance seeking, the behavior should be considered as a potential target in treatment for anxiety disorders.

Targeting intolerance of uncertainty in treatment: A meta-analysis of therapeutic effects, treatment moderators, and underlying mechanisms

OBJECTIVE

Anxiety-related disorders are among the most prevalent psychiatric conditions and cause significant impairment. Intolerance of uncertainty (IU) contributes to the emergence, maintenance, and symptom severity of anxiety-related disorders, yet information regarding treatment-related changes in IU is limited. This systematic review and meta-analysis examined the efficacy of evidence-based treatments for anxiety-related disorders on IU, explored factors moderating treatment effects of IU, and examined whether therapeutic improvement in IU corresponded with improvements in anxiety symptom severity.

METHODS

PubMED and PsycINFO were searched for randomized controlled trials (RCTs) using the terms "intolerance of uncertainty" AND "treatment" OR "therapy." Data for pre and post-treatment measures and patient, intervention, and trial-level characteristics were extracted from 28 RCTs. Separate random effects models examined the treatment efficacy of interventions on IU and symptom severity. Moderators of therapeutic effects were analyzed via method-of-moments meta-regression or an analog to the analysis of variance.

RESULTS

Across RCTs, interventions exhibited a large therapeutic effect on IU compared to control conditions (g = 0.89). Treatment effects on IU positively corresponded with improved symptom severity and accounted for 36 % of the variance. Interestingly, comorbid depression and certain treatment approaches were associated with larger improvements in IU.

CONCLUSION

Evidence-based treatments are effective in improving IU, highlighting the importance of IU in the treatment of anxiety-related disorders. Moderator analyses identified patient and intervention-level factors to inform approaches to improve therapeutic effects on IU. Future research is needed to optimize interventions targeting IU and evaluate long-term efficacy of interventions on IU for anxiety-related disorders.

The role of uncertainty intolerance in adjusting to long-term physical health conditions: A systematic review

Long-term physical health conditions (LTPHCs) are associated with poorer psychological well-being, quality of life, and longevity. Additionally, individuals with LTPHCs report uncertainty in terms of condition aetiology, course, treatment, and ability to engage in life. An individual's dispositional ability to tolerate uncertainty-or difficulty to endure the unknown-is termed intolerance of uncertainty (IU), and may play a pivotal role in their adjustment to a LTPHC. Consequently, the current review sought to investigate the relationship between IU and health-related outcomes, including physical symptoms, psychological ramifications, self-management, and treatment adherence in individuals with LTPHCs. A systematic search was conducted for papers published from inception until 27 May 2022 using the databases PsycINFO, PubMed (MEDLINE), CINAHL Plus, PsycARTICLES, and Web of Science. Thirty-one studies (N = 6,201) met the inclusion criteria. Results indicated that higher levels of IU were associated with worse psychological well-being outcomes and poorer quality of life, though impacts on self-management were less clear. With the exception of one study (which looked at IU in children), no differences in IU were observed between patients and healthy controls. Although findings highlight the importance of investigating IU related to LTPHCs, the heterogeneity and limitations of the existing literature preclude definite conclusions. Future longitudinal and experimental research is required to investigate how IU interacts with additional psychological constructs and disease variables to predict individuals' adjustment to living with a LTPHC.

Transdiagnostic factors in symptoms of depression and post-traumatic stress: a systematic review

The current systematic review sought to identify quantitative empirical studies that focused on the transdiagnostic factors of intolerance of uncertainty, emotional dysregulation and rumination, and their relation with depression and post-traumatic stress disorder (PTSD). The overall research aim was to examine the relationship between these transdiagnostic factors and their relation with depression and PTSD symptoms. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Out of the 768 articles initially identified, 55 met the inclusion criteria for the current review. The results determined that intolerance of uncertainty is indirectly related to depression and PTSD symptoms, mainly through other factors including emotion dysregulation and rumination. Additionally, emotional dysregulation is a significant predictor of both depression and PTSD symptoms. Rumination is a robust factor related to depression and PTSD symptoms, this relationship was significant in cross-sectional and longitudinal studies. This review provides evidence on the transdiagnostic factors of intolerance of uncertainty, emotional dysregulation and rumination in the relationship with depression and PTSD symptoms.

Do perfectionists show negative, repetitive thoughts facing uncertain situations?

Perfectionism, intolerance of uncertainty and repetitive negative thinking are all psychological traits, which are treated as transdiagnostic phenomena for the development and the maintenance of psychopathology. The aim of the current work was to investigate the associations between repetitive negative thinking and the multidimensional aspects of perfectionism (perfectionistic strivings and perfectionistic concerns) and intolerance of uncertainty (prospective and inhibitory) in one model. Two studies were conducted in which participants (N1 = 227; N2 = 148) completed questionnaires in an online survey. The first study measured rumination and worry separately as repetitive negative thinking processes. The second study measured repetitive negative thinking as an underlying construct of rumination and worry using a single questionnaire. We applied hierarchical regression analyses and mediation analyses in both studies. The mediation analyses in both studies showed that inhibitory intolerance of uncertainty significantly partially mediated the relationship between perfectionistic concerns and repetitive negative thinking (as well as worry and rumination). Perfectionistic concerns seem to be the more crucial perfectionism aspect for transdiagnostic considerations, particularly in association with a heighten inhibitory intolerance of uncertainty and repetitive negative thinking. Both studies strongly affirm the necessity to use the multidimensional aspects of perfectionism and intolerance of uncertainty in psychological research.

The role of emotion dysregulation and intolerance of uncertainty in autism: Transdiagnostic factors influencing co-occurring conditions

BACKGROUND

Individuals with autism spectrum disorders (ASD) are more likely to have co-occurring psychiatric conditions such as depression and anxiety. Transdiagnostic constructs such as intolerance of uncertainty (IU) and emotion dysregulation (ED) have both been shown to be individually associated with depression and anxiety in those with ASD.

AIMS

The current study examined the relationship between IU and ED, depression, and anxiety in an ED treatment-seeking sample and examined whether ED acts as a mediator between IU-depression and IU-anxiety.

METHODS AND PROCEDURES

We examined baseline scores for 78 adolescents and young adults (12-21 years old) who were participating in an ED treatment. We assessed for correlations between IU, Reactivity and Dysphoria, anxiety, and depression symptoms, and then conducted mediation analyses to determine whether Reactivity and Dysphoria functioned as a mediator in IU- anxiety and IU- depression relationships.

OUTCOMES AND RESULTS

Concordant with prior research, ED, IU, anxiety, and depression scores were correlated. Both Reactivity and Dysphoria were found to mediate both IU-depression and IU-anxiety.

CONCLUSIONS AND IMPLICATIONS

Findings suggest that ED contributes to how IU affects psychopathology. Furthermore, both IU and ED may be pertinent treatment targets for individuals with depression or anxiety and ASD.

Time-Varying and Time-Invariant Dimensions in Intolerance of Uncertainty: Specificity in the Prediction of Obsessive-Compulsive Symptoms

Intolerance of uncertainty (IU) is the tendency to respond negatively toward uncertain situations. IU consists of a Prospective factor (desire for predictability) and an Inhibitory factor (uncertainty paralysis) and is central to theoretical approaches to obsessive-compulsive disorder (OCD). However, time-invariant (TI) and time-varying (TV) components of IU and their association with OCD symptoms are not yet understood. The present study examined the association between TI and TV components of IU and OCD symptoms in community adults (N = 1,280) over a 5-month period. Latent variable models were fit to the data to examine the relative impact of TI and TV components of IU on OCD symptoms. As a test of specificity, models examining the association between TI and TV components of IU and depressive symptoms were also examined. The results showed that IU consists of significant TI and TV components, although the TI component accounted for most of the variance (76-84%) and was more strongly associated with OCD and depressive symptoms than the TV component. Furthermore, the TI component of IU was strongly associated with OCD symptoms when controlling for depressive symptoms, and the TI component of IU was strongly associated with depressive symptoms when controlling for OCD symptoms. A consistent pattern was observed for both Prospective and Inhibitory IU factors, with stable TI components demonstrating stronger relations with OCD and depressive symptoms than TV components. These findings have implications for conceptualizing the TI component of IU as a risk for OCD and other emotional disorders.

COVID-19 Related Stresses, Conspiracy Beliefs, Uncertainty, and Non-adherence to Safety Guidelines

INTRODUCTION

Inconsistent use of protective preventive measures and nonadherence of the guidelines set by the World Health Organization regarding the coronavirus are associated with increased morbidity and mortality, as well as increased health care costs.

OBJECTIVE

The purpose of this study was to examine the role of COVID-19 related worries, conspiracy beliefs, and uncertainty in adherence to preventative measures in Iran.

METHOD

In a large survey with data collected online from a volunteer sample of 599 individuals, assessments were made of the distress associated with the anticipated potential consequences associated with the COVID-19 pandemic and the lockdown, extent of agreement with conspiracy beliefs, level of situation-specific uncertainty, and self-reports of compliance with preventive measures. Data were analyzed to explore paths leading to nonadherence to safety guidelines proposed by the medical authorities.

RESULTS

A large majority of individuals report significant distress and worry associated with the COVID-19 pandemic. Results indicate that increasing levels of situation-specific uncertainty intolerance, as well as conspiracy beliefs regarding the coronavirus, are associated with non-compliance with the advised protocols. Specifically, the results show that worries related to the COVID-19 pandemic are linked to non-compliance with preventive measures through conspiracy beliefs and feelings of uncertainty associated with the COVID-19 situation even after gender, education, and perceived socioeconomic status were controlled.

CONCLUSIONS

Findings imply that emotional exhaustion is likely to have set in and become counterproductive as people choose to violate safety guidelines. The authors discuss the theoretical and practical implications of these results.

Life goals and proactive career behaviors: The mediating role of visions about the future and the moderating role of intolerance of uncertainty

Dominated by uncertainties, today's work world pushed university students to exhibit proactive career behaviors. Thus, this created a need for more research conducted to determine the variables associated with proactive career behaviors, on the grounds that additional research may contribute to an increase in proactive career behaviors. In this context the study explored the mediating role of visions about the future and the moderating role of intolerance of uncertainty in the relationship between university students' life goals and their proactive career behaviors. The study was carried out with 519 students (299 females and 220 males) studying at a university in the Eastern Mediterranean Region of Turkey. The Scale of Setting Life Goals with Respect to Positive Psychotherapy, the Visions about the Future Scale, the Career Engagement Scale, and the Intolerance of Uncertainty Scale were employed as data collection tools. Data were analyzed using correlation analysis, structural equation modeling methods, and regression analysis based on the bootstrap method. The correlation analysis revealed a positive relationship between proactive career behaviors, life goals and visions about the future, and a negative relationship between proactive career behaviors and intolerance of uncertainty. Furthermore, the analyses put forth that visions about the future have a mediating role in the relationship between life goals and proactive career behaviors and that intolerance of uncertainty has a moderating role in the same relationship. Increasing university students' life goals and their visions about the future and reducing their intolerance of uncertainty will help them exhibit proactive career behaviors.

Maladaptive metacognitive beliefs mediated the effect of intolerance of uncertainty on depression

Both elevated intolerance of uncertainty (IU) and maladaptive metacognitive beliefs (MBs) were associated with depression. However, the relationship between MBs and IU in clinical depression is unclear. The current study aimed to investigate the putative impairment of MBs and IU in major depressive disorder (MDD) and explore the relationship between these two factors with depressive symptoms. Metacognition Questionnaire-30 Items (MCQ-30), Intolerance of Uncertainty Scale-Short Form (IUS-12) and clinical rating scales were administered to 53 patients with MDD and 56 healthy controls (HCs). Stepwise regressions were performed to explore independent contributions of MBs and IU on depression. Mediation analysis was used to examine associations among variables. Patients with MDD reported higher IUS-12 and MCQ-30 scores than HCs. Stepwise regressions revealed a unique contribution of negative MBs concerning the consequences of not controlling thoughts (MCQ-NC) on depression symptoms while controlling the effects of age, gender, anxiety symptoms and IU. MCQ-NC and negative MBs concerning the uncontrollability and danger of negative thinking (MCQ-NEG) completely mediated the effects of IU on depression and anxiety symptoms. Our results provided clear evidence that maladaptive negative MBs are directly associated with depression symptoms, and mediated the effect of IU on depression and anxiety symptoms, suggesting that IU and MBs influence clinical symptoms in a hierarchical manner.

Intolerance of uncertainty, rumination, post-traumatic stress symptoms and aggression during COVID-19: a serial mediation model

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic can be identified as a source of traumatic stress. Previous studies have shown that post-traumatic stress and intolerance of uncertainty are associated with aggressive behaviour.

OBJECTIVE

In the present study, we aimed to test a serial mediation model, considering rumination and post-traumatic stress symptoms (PTSS) as mediators that link intolerance of uncertainty and aggression, while controlling the confounding effect of crisis-induced health and socioeconomic stressors during the COVID-19 pandemic.

METHOD

A total of 714 participants [533 (74.6%) females, 176 (24.7%) males, aged 18-64 years (M _age = 25.16, SD _age = 9.34)] completed the following self-reported scales: Aggression Scale, COVID-19 stressors checklist, Short Version of the Intolerance of Uncertainty Scale, Impact of Event Scale with Modifications for COVID-19, and Ruminative Thought Style Questionnaire.

RESULTS

The results revealed that there was an association between intolerance of uncertainty and aggressive behaviours. Moreover, the results of serial mediation analysis showed that intolerance of uncertainty predicts aggressive behaviours via rumination and PTSS. Besides, socioeconomic stressors are significantly associated with the level of PTSS and aggression, while health stressors are not significantly association with the level of PTSS and aggression.

CONCLUSIONS

The findings provide several contributions to understand the link between intolerance of uncertainty and aggressive behaviours during the COVID-19 pandemic, and confirm the importance of early psychological intervention, especially for those who are more likely to ruminate and suffer from PTSS, to prevent aggression and violence in the long run. In addition to health-related regulations, it is important to take the social and economic aspects of the crisis into account and develop intervention strategies accordingly. Nevertheless, the limitations of cross-sectional mediation analysis in explaining causal relationships should be kept in mind, and future studies should extend these findings using longitudinal data.