Available online at www.sciencedirect.

com

Behavior Therapy 43 (2012) 533 545

www.elsevier.com/locate/bt

To Be Sure, To Be Sure: Intolerance of Uncertainty Mediates Symptoms of Various Anxiety Disorders and Depression
Peter M. McEvoy Centre for Clinical Interventions, Perth University of Western Australia, Perth Alison E.J. Mahoney Clinical Research Unit for Anxiety and Depression, Sydney
were associated with significant indirect effects, although the mediation effect was stronger for worry than other symptoms. Potential implications of these findings for the treatment of anxiety disorders and depression are discussed.

The Intolerance of Uncertainty Model was initially developed as an explanation for worry within the context of generalized anxiety disorder. However, recent research has identified intolerance of uncertainty (IU) as a possible transdiagnostic maintaining factor across the anxiety disorders and depression. The aim of this study was to determine whether IU mediated the relationship between neuroticism and symptoms related to various anxiety disorders and depression in a treatment-seeking sample (N = 328). Consistent with previous research, IU was significantly associated with neuroticism as well as with symptoms of social phobia, panic disorder and agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, and depression. Moreover, IU explained unique variance in these symptom measures when controlling for neuroticism. Mediational analyses showed that IU was a significant partial mediator between neuroticism and all symptom measures, even when controlling for symptoms of other disorders. More specifically, anxiety in anticipation of future uncertainty (prospective anxiety) partially mediated the relationship between neuroticism and symptoms of generalized anxiety disorder (i.e. worry) and obsessive-compulsive disorder, whereas inaction in the face of uncertainty (inhibitory anxiety) partially mediated the relationship between neuroticism and symptoms of social anxiety, panic disorder and agoraphobia, and depression. Sobel's test demonstrated that all hypothesized meditational pathways

Keywords: intolerance of uncertainty; anxiety; depression; transdiagnostic; mediation

Address correspondence to Peter M. McEvoy, Ph.D., Centre for Clinical Interventions, 223 James Street, Northbridge, Perth, Western Australia, 6003; e-mail: peter.mcevoy@health.wa.gov.au.
0005-7894/43/533-545/$1.00/0 2011 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

INTOLERANCE OF UNCERTAINTY (IU) has been broadly defined as cognitive, emotional, and behavioral reactions to uncertainty that bias information processing and lead to faulty appraisals of heightened threat and reduced coping (Freeston, Rhaume, Letarte, Dugas, & Ladouceur, 1994). The Intolerance of Uncertainty Model (IUM) was initially developed with reference to generalized anxiety disorder (GAD; Dugas, Letarte, Rhaume, Freeston & Ladouceur, 1995; Freeston et al., 1994), which is characterized by excessive and uncontrollable worry (American Psychiatric Association, 1994). More recently, however, it has been argued that IU might be a transdiagnostic mechanism that contributes to the maintenance of symptoms across anxiety disorders and depression (e.g., Boelen & Reijntjes, 2009; McEvoy & Mahoney, 2011). If IU is demonstrated to be related to multiple internalizing disorders, this would have important implications for the development of innovative transdiagnostic treatment protocols. The IUM suggests that individuals with GAD find uncertainty distressing, which leads to the commencement of worrying when confronted with an uncertain or ambiguous situation (e.g., What if [something bad]

534

McEvoy & Mahoney

and wait-list control for GAD. While both active treatment conditions were more effective than waitlist control, the CBT condition was most effective, particularly in the longer term. In sum, the evidence that IU motivates engagement in worry is strong. Evidence has recently been accumulating that IU is also associated with symptoms of other anxiety disorders and depression. For instance, IU has been associated with symptoms of obsessive-compulsive disorder (OCD). Tolin, Abramowitz, Brigidi, and Foa (2003) found that IU was higher in compulsive checkers and repeaters, compared to obsessivecompulsive noncheckers and nonanxious controls, and Holaway, Heimberg, and Coles (2006) found that IU was equally associated with symptoms of GAD and OCD, compared to nonanxious controls. Using a mixed sample of compulsive checkers and nonclinical controls, Lind and Boschen (2009) found that IU fully mediated the relationship between responsibility appraisals and checking behavior. Importantly, IU has also been found to predict OCD symptoms after controlling for mood and worry (Steketee, Frost, & Cohen, 1998), and Dugas, Gosselin, and Ladouceur (2001) found that OCD symptoms and worry were unique predictors of IU, when controlling for demographics and panic symptoms. An association has also been found between IU and social anxiety. IU has been found to explain unique variance in symptoms of social phobia, even after controlling for related constructs such as fear of negative evaluation, anxiety sensitivity, positive and negative affectivity, low self-esteem, worry, and neuroticism (Boelen & Reijntjes, 2009; Carleton, Collimore, & Asmundson, 2010). Carleton et al. found that the degree to which one is paralyzed in the face of uncertainty (i.e., inhibitory anxiety subscale of the Intolerance of Uncertainty Scale [IUS-IA]) was robustly, uniquely, and significantly related to social anxiety symptoms when controlling for positive and negative affectivity, fear of negative evaluation, and anxiety sensitivity. Furthermore, IU has been found to be positively associated with changes in social anxiety over a subsequent 1-week period (Riskind, Tzur, Williams, Mann, & Shahar, 2007) and a significant predictor of social comparisons (Butzer & Kuiper, 2006). There is also evidence that IU is related to anxiety sensitivity (AS), which has been implicated in the development and maintenance of panic disorder and agoraphobia (PD/A). Carleton, Sharpe, and Asmundson (2007) speculated that the association between AS and IU may result from those with PD/A being intolerant of uncertainty about physical symptoms of anxiety. This suggestion implies that although trait IU might be more strongly related to

happens?). The extent to which these individuals believe that worrying can be helpful (e.g., worrying will help to prevent bad things from happening) will then determine whether they are motivated to continue engaging in worrisome thoughts, which, in turn, leads to anxiety. The IUM outlines two feedback loops. The first suggests that anxiety leads to a negative problem orientation, which is associated with the belief that problems are threatening as well as low problem-solving confidence, which increases the intensity of worry. The second feedback loop suggests that anxiety also leads to cognitive avoidance, whereby the individual is motivated to engage in unhelpful strategies such as thought suppression, distraction, and thought replacement. In the short term these strategies might be negatively reinforced by a reduction in worrisome thoughts and anxiety. However, they also prevent underlying threat appraisals from being modified, which ultimately results in more worrisome thoughts, thereby completing the cycle. The model acknowledges the impact of life stressors and mood state, and the end point is exhaustion and demoralization (Behar, DiMarco, Hekler, Mohlman, & Staples, 2009). There is considerable evidence that IU is a cognitive vulnerability factor for worry (Koerner & Dugas, 2008; Ladouceur, Gosselin, & Dugas, 2000; Sexton, Norton, Walker, & Norton, 2003; van der Heiden et al., 2010) and may be an important maintaining factor for GAD (Behar et al., 2009; Dugas, Gagnon, Ladouceur, & Freeston, 1998). IU is consistently associated with worry (e.g., Berenbaum, Bredemeier, & Thompson, 2008) and has been found to be a more robust predictor than several other proposed maintaining factors, including positive metabeliefs, negative problem orientation, cognitive avoidance, perfectionism, perceived control, and intolerance of ambiguity (Buhr & Dugas, 2006; Laugesen, Dugas, & Bukowski, 2003). Experimental studies have also found reliable associations between IU and worry (Buhr & Dugas, 2009; Ladouceur, Talbot, & Dugas, 1997; Ladouceur et al., 2000; Rosen & Knuper, 2009). IU has been found to distinguish between nonclinical worriers and those with GAD of varying severity (Dugas et al., 2007; Ladouceur, Blais, Freeston, & Dugas, 1998), and van der Heiden et al. (2010) found that the relationship between neuroticism and symptoms of GAD was mediated by both IU and negative metacognitions in a clinical sample with primary GAD. Finally, changes in IU are associated with improvements in worry and anxiety symptoms during cognitivebehavioral therapy (CBT; Dugas & Ladouceur, 2000; Dugas et al., 2003). Dugas et al. (2010) compared CBT targeting IU to applied relaxation

intolerance of uncertainty mediates symptoms

GAD, IU is nonetheless relevant to the core fear in each disorder. In contrast, Dugas, Marchand, and Ladouceur (2005) found that symptoms of PD/A, as measured by the Bodily Sensations Questionnaire and Agoraphobic Cognitions Questionnaire, were not significantly correlated with IU. These researchers also found that patients with PD/A endorsed the IUS less strongly than those with GAD. However, a nonclinical control was not used in this study, so it was not possible to determine whether the mean IUS score for the PD/A group was still elevated. Previous studies using the IUS have found lower means in nonclinical samples without GAD symptoms (e.g., M = 43.8, SD = 10.8; Freeston et al., 1994) compared to the patients with PD/A in Dugas et al.'s study (M = 63.2, SD = 20.34), which suggests that IU may still be elevated in PD/A. Sexton et al. (2003) investigated a hierarchical model with neuroticism leading to IU and AS, which, in turn, lead to symptoms of OCD, health anxiety, panic disorder (Beck Anxiety Inventory [BAI]), and worry. Neuroticism was considered to be a higherorder factor common to all anxiety disorders that arose from genetic influences and early childhood learning, whereas IU and AS were considered to be second-order and potentially disorder-specific factors. Path analysis showed that in the hypothesized model neuroticism made direct contributions to the prediction of panic symptoms, OCD symptoms, and worry, supporting the theory that neuroticism is a global vulnerability factor that directly influences multiple anxiety manifestations. Neuroticism also directly influenced AS and IU, which were purported to be specific vulnerability factors. AS made direct contributions to the prediction of panic symptoms, health anxiety, and OCD symptoms, whereas IU only made a direct contribution to worry. These findings suggest that IU may be a specific vulnerability factor for worry rather than a common factor across anxiety disorders. However, there are alternative explanations for this finding and further questions remain to be answered. First, Sexton et al.'s study included a nonclinical student sample, so it is unclear whether the findings would generalize to a clinical sample with more severe psychopathology. Second, the sample size was relatively small (N = 91), which may have underpowered the analyses to detect important effects. Third, symptoms were limited to panic, health anxiety, OCD, and worry, so it is unclear whether IU could contribute to the prediction of symptoms related to other emotional disorders such as social phobia and depression. There is accumulating evidence that IU is also associated with depression, although the relative strength of this association compared to that between IU and symptoms of other disorders has

535

been variable. In an undergraduate sample, Dugas, Schwartz, and Francis (2004) found that while IU was more strongly associated with worry than depression, both worry and depression explained unique variance in IU. In an analog sample with varying degrees of somatic and cognitive GAD symptoms, Buhr and Dugas (2002) found that IU was not more strongly associated with worry than depression or anxiety symptoms. Interestingly, de Jong-Meyer, Beck, and Riede (2009) found that in a community sample IU was more strongly correlated with depression than anxiety symptoms, and that IU continued to be significantly associated with depression when controlling for metacognitive beliefs. In a dysphoric sample included in the same study, however, although IU was significantly correlated with depression symptoms, it did not explain unique variance above and beyond metacognitive beliefs. Importantly, van der Heiden et al. (2010) found that the relationship between neuroticism and depression symptoms was mediated by both IU and negative metacognitions in a clinical sample. Thus, IU appears to be associated with depression symptoms, although the strength of this association relative to other symptoms and cognitive constructs has varied across studies. In sum, IU appears to be associated with a broad array of anxiety and depressive disorders and thus may represent an important transdiagnostic maintaining factor (Starcevic & Berle, 2006). However, there are several limitations of existing studies. First, most studies have used nonclinical samples, bringing into question the generalizability of the findings to treatment-seeking individuals with various anxiety and depressive disorders. Second, some studies focus on the relative strength of endorsement of IU across diagnostic or analog groups (i.e., compare group means), rather than examining the relative contribution of IU to symptoms across disorder-related symptoms or testing meditational models. Although individuals with GAD might endorse measures of IU more strongly than other disorder groups, IU may nonetheless be an important contributor to symptoms of other disorders. Third, many studies have examined IU within the context of a single diagnostic group or with diagnosis-specific symptom measures, which precludes examination of IU as a transdiagnostic process. This study sought to address these limitations by using a large mixed-diagnosis clinical sample to test whether IU mediates the relationship between neuroticism and symptoms of GAD, PD/A, social phobia, OCD, and depression. Moreover, recent research has suggested that different aspects of IU are associated with symptoms of different anxiety and depressive disorders, so this study also sought to examine

536

McEvoy & Mahoney

general practitioners or psychiatrists. At the initial assessment participants completed the standard questionnaire battery and were diagnosed via a semistructured clinical interview with a consultant psychiatrist. Diagnoses from the Composite International Diagnostic InterviewAuto (CIDI-Auto; World Health Organization, 1997) were available for 106 of the participants to provide an indication of the frequency of anxiety and affective disorders. The proportions of these patients meeting criteria for each diagnosis were panic disorder with or without agoraphobia (PD/A) = 52%, GAD = 50%, social phobia = 45%, specific phobia = 27%, OCD = 21%, PTSD = 7%, major depressive disorder (MDD) = 43%, bipolar disorder = 4%, and dysthymic disorder = 11%. The mean number of diagnoses was 3.2 (SD = 1.96), with 76% having two or more diagnoses, 59% with three or more, and 42% having four or more. Considering those with the disorders most closely related to the five symptom measures in this study (social phobia, GAD, PD/A, OCD, MDD), the most common comorbid disorder for those with social phobia was GAD (74%), followed by PD/A (67%), MDD (48%), and OCD (23%). For PD/A, the most common comorbid diagnosis was GAD (52%), followed by social phobia (51%), MDD (47%), and OCD (26%). For GAD the most common comorbid disorder was social phobia (67%), followed by PD/A (62%), MDD (44%), and OCD (27%). For OCD the most common comorbid diagnosis was PD/A (74%), followed by GAD (63%), social phobia (47%), and MDD (42%). Finally, the most common comorbid diagnosis for MDD was PD/A (67%), followed by GAD (51%), social phobia (50%), and OCD (24%). Mean age was 34.1 years (SD = 11.76). Twenty-three percent of the sample had completed high school, 32% were married or in de facto relationships, 59% never married, and 9% were separated or divorced.

whether these differences extended to mediation effects between neuroticism and symptoms. Specifically, Carleton, Norton, and Asmundson (2007) found that a 12-item version of the IUS (Freeston et al., 1994) provided the best fit to the data from two undergraduate samples, and that the total score correlated with worry, symptoms of GAD, depression, and anxiety. This version of the IUS is comprised of two subscales, namely, prospective anxiety (IUS-PA) and inhibitory anxiety (IUS-IA). Prospective anxiety relates to fear and anxiety in anticipation of uncertainty, whereas inhibitory anxiety relates to inaction in the face of uncertainty. A recent study with a treatment-seeking sample found that the IUS was significantly associated with diagnosis-related symptoms for PD/A, social phobia, OCD, GAD, and depression, even when controlling for all other symptom measures and neuroticism (McEvoy & Mahoney, 2011). Moreover, the IUS-PA was uniquely associated with symptoms of GAD and OCD, whereas the IUS-IA was uniquely associated with symptoms relating to the phobic disorders (social phobia, PD/A) and depression. The only other study using this version of the IUS in a clinical sample also found that inhibitory anxiety, but not prospective anxiety, was uniquely associated with social anxiety symptoms (Carleton et al., 2010). Together, these findings suggest that individuals with GAD and OCD particularly fear future uncertainty, which is consistent with the fact that worry and obsessions are often future oriented (i.e., anticipatory). In contrast, those with phobic disorders and depression are more paralyzed in the face of uncertainty, which is consistent with the fact that phobic disorders and depression are associated with inaction and withdrawal (i.e., inhibition). Thus, IU was found to be a transdiagnostic phenomenon, although different aspects of IU were related to different symptoms of internalizing disorders. This study sought to extend these findings by testing whether IU mediates the relationship between the general vulnerability factor of neuroticism and symptoms of various anxiety disorders and depression. Guided by the findings of McEvoy and Mahoney (2011) and Carleton et al. (2010), it was hypothesized that the IUS-PA would mediate the relationship between neuroticism and symptoms of GAD and OCD. It was further expected that the IUS-IA would mediate the relationship between neuroticism and symptoms of social anxiety, PD/A, and depression.

Method
participants Participants (N = 328, 54% women) were referred to a specialist anxiety disorders treatment service by

measures Composite International Diagnostic InterviewAuto The CIDI-Auto was used to assess the presence of anxiety and depressive disorders in the current sample. The CIDI-Auto is a computerized, selfreported, structured diagnostic interview for mental disorders according to International Classification of Diseases (ICD-10; World Health Organization, 1993) and the DSM-IV (American Psychiatric Association, 1994). It has demonstrated procedural validity against expert clinical diagnoses (Peters & Andrews, 1995) and has good reliability (Andrews & Peters, 1998; Wittchen, 1994).

intolerance of uncertainty mediates symptoms

Intolerance of Uncertainty Scale The original English version of the IUS (Buhr & Dugas, 2002) is composed of 27 items and measures negative beliefs about and reactions to uncertainty (e.g., Uncertainty makes life intolerable). Internal consistency ( = .94) and testretest reliability (r = .74 over 5 weeks) are good (Buhr & Dugas, 2002). Evidence of discriminant, convergent, content, and criterion validity have been reported in multiple populations (Buhr & Dugas, 2002, 2006; Carleton, Norton, et al., 2007; Norton, 2005). The 12-item version has been found to be highly correlated (r = .96) with the full version in two studies with both undergraduate (Carleton, Norton, et al., 2007) and clinical samples (McEvoy & Mahoney, 2011), and is comprised of two subscales: IUS-PA and IUS-IA. The IUS-PA measures anxiety in anticipation of uncertainty (e.g., I always want to know what the future has in store for me), whereas the IUS-IA measures inhibition of action or experience (e.g., When it's time to act, uncertainty paralyzes me). Penn State Worry Questionnaire The Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger & Borkovec, 1990) is a widely used 16-item measure of worry with excellent internal consistency ( = .86 .95) and good temporal stability (r = .92 over 8 to 10 weeks and r = .74 .93 over 4 weeks; Meyer et al., 1990; Molina & Borkovec, 1994). The measure has demonstrated evidence of construct validity in clinical and community populations (e.g., Brown, Antony, & Barlow, 1992; van Rijsoort, Emmelkamp, & Vervaeke, 1999). Body Sensations Questionnaire and Agoraphobic Cognitions Questionnaire The Body Sensations Questionnaire (BSQ) and the Agoraphobic Cognitions Questionnaire (ACQ; Chambless, Caputo, Bright, & Gallagher, 1984) are established self-report measures of symptoms associated with PD/A. The scales measure the physical sensations and thoughts respondents typically experience when they are nervous or frightened. Internal consistency ( = .80 and .87 for ACQ and BSQ, respectively) is good, and evidence of temporal stability and construct validity have been well provided (see Chambless, Beck, Gracely, & Grisham, 2000; Chambless & Gracely, 1989; Chambless et al., 1984). Beck Depression InventoryII The Beck Depression InventoryII (BDI-II; Beck, Steer, & Brown, 1996) is a 21-item measure of the severity of depression symptoms experienced during the previous fortnight. Internal consistency ( = .92)

537

and testretest reliability (r = .93 over 1 week) are established (Beck et al., 1996), and evidence for construct validity has been demonstrated (e.g., Dozois, Dobson, & Ahnberg, 1998; Osman, Kopper, Barrios, Gutierrez, & Bagge, 2004). Social Phobia Scale and Social Interaction Anxiety Scale The Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998) are widely used, 20-item measures of performance and interaction anxiety, respectively. The SPS describes situations in which the person is the focus of attention and observed by others, such as eating, drinking, and writing. The SIAS contains items reflecting cognitive, affective, and behavioral reactions to interactional situations, such as nervousness when speaking to authority, mixing with people, and talking to an attractive person of the opposite sex. The 5-point response scale for both scales is not at all, slightly, moderately, very, or extremely characteristic of me. Internal reliabilities for the SPS ( = .89) and SIAS ( = .93) are high within clinical samples and these scales have been shown to be sensitive to change (Cox, Ross, Swinson, & Direnfeld, 1998; Mattick, Peters, & Clarke, 1989). Eysenck Personality QuestionnaireNeuroticism Subscale The 23-item neuroticism subscale of the Eysenck Personality Questionnaire (EPQ-N; Eysenck & Eysenck, 1975) was used in the current study. Data demonstrating reliability and validity of the EPQ-N are extensive (e.g., see Barrett, Petrides, Eysenck, & Eysenck, 1998; Caruso, Witkiewitz, Belcourt-Dittloff, & Gottlieb, 2001). Padua InventoryWashington State University Revision The Padua InventoryWashington State University Revision (PI; Burns, 1995) is a widely used 39-item self-report measure of OCD symptoms. Each item (e.g., I feel my hands are dirty when I touch money) is rated on a 5-point scale according to the degree of disturbance caused by the thought or behavior from 0 (not at all) to 4 (very much). Although subscale scores are available, the total score was used in the current study. Evidence of construct, convergent, and discriminant validity has been demonstrated (Burns, Keortge, Formea, & Sternberger, 1996; Jnsdttir & Smri, 2000).

procedure Patients referred to a specialist anxiety disorders clinic completed a standard battery of questionnaires during their initial assessment, including the

538

McEvoy & Mahoney

Table 1

IUS, PSWQ, BSQ, ACQ, PI, SPS, SIAS, BDI-II, and EPQ-N. Data were available for 328 patients. In addition, a subsample completed the CIDI-Auto as a structured diagnostic assessment of anxiety and affective disorders (n = 106). All patients consented for their data to be used for research purposes and the use of the data was approved by the hospital's Human Research Ethics Committee.

Means, Standard Deviations and Cronbach's Alphas for Symptom Measures, Neuroticism, and Intolerance of Uncertainty
Measure Mean SD

Results
data screening Prior to data analyses, distributions, skewness, and kurtosis were examined for scale total scores (ACQ, BSQ, BDI-II, EPQ-N, PSWQ, SIAS, SPS, PI, IUS-PA, IUS-IA). Scores were generally normally distributed with most items demonstrating acceptable levels of skewness and kurtosis (b |1.00|). One exception to this was the PI total score, with a skew of 1.33 and kurtosis of 1.57. A square-root transformation reduced these values to .51 and .25, respectively. All subsequent analyses were conducted with this transformed variable (PIsqrt). Total scores were then screened for univariate and multivariate outliers. Eight participants were removed because they had standardized total scores greater than 3 on at least one variable, suggesting that they were univariate outliers. Mahalanobis Distance with a chi-square cutoff of 29.59 (10 variables, p = .001) indicated one multivariate outlier, which was removed. Thus, the final total was 319 participants, who were used for all subsequent analyses.
Scale Descriptive Statistics and Internal Consistency Means, standard deviations, and internal reliability estimates (Cronbach's ) for symptom measures, neuroticism, and IUS subscales are reported in Table 1. The means place the sample in the clinical range on the SPS and SIAS (Mattick & Clarke, 1998), PSWQ (Brown et al., 1992; Gillis, Haaga, & Ford, 1995), and BSQ and ACQ (Chambless et al., 1984; Chambless & Gracely, 1989). While the total sample mean on the PI fell within the nonclinical range, the mean score for participants with a CIDIAuto diagnosis of OCD ( n = 19, M = 57.37, SD = 24.54) fell within the clinical range (Burns et al., 1996). Mean score on the BDI-II placed the sample in the moderate range for depression. Therefore, on average, the current sample experienced symptoms in the clinical range. The alphas range from good to excellent.

IUS-PA IUS-IA EPQ-N BSQ ACQ PSWQ SIAS SPS PI BDI-II

21.87 15.53 17.98 42.54 28.76 63.92 42.12 31.82 27.48 23.25

6.73 5.04 3.46 15.30 9.77 11.43 18.69 19.03 22.63 12.38

.87 .86 .79 .93 .85 .74 .90 .94 .94 .93

Note. BSQ = Bodily Sensation Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SIAS = Social Interaction Anxiety Scale, SPS = Social Phobia Scale, PI = Padua Inventory (untransformed), BDI-II = Beck Depression Inventory-II, EPQ-N = Eysenck Personality Questionnaire Neuroticism subscale, IUS-PA = Intolerance of Uncertainty Scale Prospective Anxiety subscale, IUS-IA = Intolerance of Uncertainty Scale Inhibitory Anxiety subscale.

test of mediation effects Composite scores were created for social anxiety (SPS + SIAS/2) and PD/A (BSQ + ACQ/2) prior to analysis, because these measures were considered to measure different aspects of the same disorder groups studied

here (social phobia and panic disorder with or without agoraphobia, respectively). The SPS and SIAS were correlated at .72 and the composite score was correlated at .93 with both measures, suggesting that the composite score reflected scores on both measures. Likewise, the BSQ and ACQ were correlated at .71 and the composite score correlated at .96 with the BSQ and .89 with the ACQ, suggesting that the composite score reflected scores on both measures. The IUS-PA and the IUS-IA were significantly associated with neuroticism, as well as all symptom scores (all ps b .001; see Table 2). Previous research with an almost identical sample to the one used in this study found that IUS-PA was uniquely associated with PSWQ and PI, whereas IUS-IA was uniquely associated with SPS/SIAS composite, BSQ/ACQ composite, and BDI-II (McEvoy & Mahoney, 2011). We reran these analyses with this sample and found an identical pattern of results so they are not reported again here. Therefore, in this study it was expected that PI would mediate the relationship between neuroticism and PSWQ and PIsqrt, whereas IUS-IA would mediate the relationship between neuroticism and ACQ/BSQ, SPS/SIAS, and BDI-II. A series of linear regression analyses were conducted to determine whether the four conditions needed to establish mediation were met (Baron & Kenny, 1986). Dependent variables were the symptom measures. The first condition to establish mediation is that the independent variable (neuroticism) is significantly related to the dependent variables (symptom measures). This condition was

intolerance of uncertainty mediates symptoms

Table 2

539

Pearson Bivariate Correlation Coefficients Between Intolerance of Uncertainty Subscales, Neuroticism, and Symptom Measures
Symptom Measure IUS-PA IUS-IA EPQ-N BSQ/ACQ PSWQ SIAS/SPS PIsqrt

IUS-IA EPQ-N BSQ/ACQ composite PSWQ SIAS/SPS composite PIsqrt BDI-II

.73* .49* .37* .54* .37* .36* .43*

.49* .39* .49* .49* .32* .51*

.36* .56* .40* .38* .51*

.31* .27* .33* .48*

.39* .33* .43*

.32* .40*

.37*

Note. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SIAS = Social Interaction Anxiety Scale, SPS = Social Phobia Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression Inventory-II, EPQ-N = Eysenck Personality Questionnaire Neuroticism subscale, IUS-PA = Intolerance of Uncertainty Scale Prospective Anxiety subscale, IUS-IA = Intolerance of Uncertainty Scale Inhibitory Anxiety subscale. * p b .001.

met, with neuroticism being significantly associated with all symptom measures (see Step 1, Path c, in Table 3). The second condition is that the independent variable (neuroticism) is significantly related to the mediators, which was also met (Step 2, Path a). While uncontrolled betas are reported, neuroticism explained unique variance in each IUS subscale even when controlling for the other mediator. The third

Table 3

Summary of Multiple Linear Regression Analyses Testing Mediation Pathways

Criterion Mediator Path B SE B

PSWQ

PA

PIsqrt

PA

BSQ/ACQ

IA

SPS/SIAS

IA

BDI-II

IA

Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step Step

1: 2: 3: 4: 1: 2: 3: 4: 1: 2: 3: 4: 1: 2: 3: 4: 1: 2: 3: 4:

Path c Path a Path b Path c' Path c Path a Path b Path c' Path c Path a Path b Path c' Path c Path a Path b Path c' Path c Path a Path b Path c'

1.84 .96 .61 1.26 .22 .96 .07 .16 1.22 .71 .65 .76 2.02 .71 1.36 1.06 1.81 .71 .85 1.21

.15 .10 .09 .17 .03 .10 .02 .03 .18 .07 .13 .20 .26 .07 .19 .28 .17 .07 .13 .19

.56* .49* .36* .38* .38* .49* .23* .27* .36* .49* .28* .23* .40* .49* .39* .21* .51* .49* .34* .34*

Note. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SPS = Social Phobia Scale, SIAS= Social Interaction Anxiety Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression Inventory, PA= Prospective Anxiety, IA = Inhibitory Anxiety. Path c = neuroticism-predicting symptoms, Path a = neuroticismpredicting mediator, Path b = mediator-predicting symptoms, Path c'= neuroticism-predicting symptoms controlling for the mediator. * p b .001.

condition is that the mediators explain a significant proportion of variance in the dependent variables (i.e., symptom measures). This condition was also met, with prospective anxiety explaining unique variance in PSWQ and PIsqrt, and inhibitory anxiety explaining unique variance in ACQ/BSQ, SPS/SIAS, and BDI-II (Step 3, Path b). The fourth condition is that the relationship between the independent variable and the dependent variable reduces in magnitude when controlling for the influence of the mediator. This condition was also met, with all associations between neuroticism and symptom measures reducing when controlling for the mediator. However, all direct relationships between neuroticism and the predictors remained significant, which is indicative of partial rather than full mediation (Step 4, Path c). The mediation model is depicted in Figure 1. Preacher and Hayes's (2004) method of calculating Sobel's test for the significance of the indirect effects was used, and bootstrapping with 5,000 resamples was used to calculate confidence intervals around the standardized indirect effect. The results of this analysis indicated a significant reduction in the relationship between neuroticism and all symptom measures once intolerance of uncertainty was accounted for (see Table 4). The indirect effect was strongest for the PSWQ, accounting for 20% of the variance, followed by the BDI-II (17%), SPS/SIAS (13%), BSQ/ACQ (9%), and PIsqrt (9%). Confidence intervals around the standardized indirect effects showed that the effect was significantly stronger for the PSWQ than the other symptom measures, which did not significantly differ from each other. In order to control for the influence of other symptom measures the indirect effects were recalculated controlling for all symptom measures sharing the same mediator using Preacher and Hayes's (2008) method. Standardized indirect effects remained statistically significant for the

540

McEvoy & Mahoney

.36* Prospective Anxiety .49* .38* (.56*) .27* (.38*) EPQ-N .23* (.36*) .21* (.40*) .49* .34* (.51*) .28* .39* Inhibitory Anxiety .34* .23*

PSWQ

PIsqrt

ACQ/BSQ

SPS/SIAS

BDI-II

FIGURE 1 Meditational model. Mediational pathways are bolded, whereas direct effects of neuroticism on symptoms are not. Beta coefficients in parentheses are direct effects of neuroticism on the respective symptom measure, prior to controlling for the mediator. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SIAS = Social Interaction Anxiety Scale, SPS = Social Phobia Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression InventoryII, EPQ-N = Eysenck Personality Questionnaire Neuroticism subscale. * p b .001

PSWQ, .14, 95% CI [.09.21]; PI, .05, 95% CI [.02.10]; BSQ/ACQ, .04, 95% CI [.01.07]; SPS/SIAS, .10, 95% CI [.05.16]; and BDI, .06, 95% CI [.03.11]. In these models the indirect effect for the PSWQ was only significantly stronger than that for the BSQ/ACQ, but not the other symptom measures. As a final conservative test the indirect effects were calculated again controlling for all symptom measures and effects remained statistically significant for the PSWQ, .09, 95% CI [.04.14]; PI, .02, 95% CI [.0001.06]; BSQ/ACQ, .02, 95% CI [.003.05]; SPS/SIAS, .05, 95% CI [.01.10]; and BDI, .09, 95% CI [.05.14]. In these

models no indirect effect was significantly stronger than any other.

Discussion
IU has traditionally been examined within the context of GAD and worry. However, recent research suggests that IU may be an important contributor to symptoms across the anxiety disorders and depression. This is the first study to examine whether IU mediated the relationship between neuroticism and symptoms of social phobia, PD/A, GAD, OCD, and depression in a single treatmentseeking clinical sample. Moreover, this study sought

Table 4

Sobel's Test of Mediation Effects

Criterion Indirect Effect SE Z Standardized Indirect Effect 95% CI [LL, UL] % of Variance a

PSWQ PIsqrt BSQ/ACQ SPS/SIAS BDI-II

.58 .07 .46 .96 .59

.10 .02 .10 .17 .11

5.81** 3.64* 4.36** 5.79** 5.49**

.18 .03 .04 .05 .05

[.12, [.01, [.02, [.04, [.03,

.24] .05] .05] .07] .07]

20% 9% 9% 13% 17%

Note. BSQ = Bodily Sensations Questionnaire, ACQ = Agoraphobic Cognitions Questionnaire, PSWQ = Penn State Worry Questionnaire, SPS = Social Phobia Scale, SIAS = Social Interaction Anxiety Scale, PIsqrt = Padua Inventory square root, BDI-II = Beck Depression Inventory. CI = Confidence Interval, LL = Lower Limit, UL = Upper Limit. a Percent of variance in the criterion variable explained by the indirect effect. * p b .01, ** p b .001.

intolerance of uncertainty mediates symptoms

to determine whether two aspects of IU, namely prospective and inhibitory anxiety, would mediate different disorder-related symptoms. The hypothesis that IU would mediate the relationship between neuroticism and symptoms of GAD (PSWQ) and OCD (PIsqrt) was partially supported, with prospective anxiety partially mediating this relationship, explaining 20% and 9% of the variance in these measures, respectively. Likewise, the hypothesis that IU would mediate the relationship between neuroticism and symptoms of social phobia (SPS/SIAS), PD/A (BSQ/ACQ), and depression (BDI-II) was also supported, with inhibitory anxiety partially mediating this relationship, explaining, 13%, 9%, and 17% of the variance in these measures, respectively. The magnitude of the indirect effects reduced somewhat when controlling for other symptom measures, suggesting that the indirect effects could be partially accounted for by the covariance in symptom measures. Importantly, however, the indirect effects remained statistically significant, even when controlling for all other symptom measures. This finding suggests that the partial mediation effects across the disorder-related symptom measures could not be fully explained by comorbid symptoms. It is noteworthy that IU was a significantly stronger mediator for worry than the other symptoms. A substantial body of previous research has found a strong and robust relationship between IU and worry and this was replicated here. Our finding is consistent with IU being more important in the maintenance of worry than some of the core symptoms of other anxiety disorders and depression that were measured in this study. An alternative explanation for this finding is that IU, being a cognitive construct, is more strongly related to worry because it is a cognitive symptom, compared to measures such as the BSQ, which measures physical symptoms of anxiety. However, the ACQ and PI also measure cognitive constructs related to agoraphobia and OCD, respectively. Yet another alternative is that IU is most strongly associated with the PSWQ because both constructs are strongly related to the underlying cognitive construct of repetitive negative thinking (RNT) in particular. There is considerable evidence that constructs tapping into RNT, such as worry, rumination, and postevent processing, share many qualities (Ehring & Watkins, 2008; McEvoy, Mahoney, & Moulds, 2010), despite them being examined almost exclusively within the anxiety, depression, and social phobia literatures, respectively. Indeed, it has been argued that these constructs may be more similar than different, with temporal orientation (i.e., future vs. past focus) being the only replicated difference (Ehring & Watkins, 2008), and

541

therefore that RNT is a transdiagnostic cognitive construct (Harvey, Watkins, Mansell, & Shafran, 2004). While the relationship between IU and worry has been well documented, the relationships between IU and other forms of RNT require further investigation, especially in diagnostically heterogeneous samples. If IU is strongly related to the underlying construct of RNT, then it may be more strongly associated with worry, depressive rumination, and postevent processing, compared to other physical, emotional, behavioral, and even cognitive symptoms, irrespective of diagnosis. Future research could examine this possibility by testing whether IU mediates the relationship between neuroticism and various measures of RNT to a similar degree. Furthermore, if IU leads to RNT, then RNT may mediate the relationship between IU and other symptoms of anxiety and depressive disorders. Taken together, such findings would argue that IU is a relatively specific vulnerability factor for RNT, rather than necessarily being particular to GAD. Consistent with this possibility, Yook, Kim, Suh, and Lee (2010) found that IU was correlated with both worry and depressive rumination in a clinical sample with MDD and/or GAD. Furthermore, meditational analyses showed that worry partially mediated the relationship between IU and anxiety symptoms, and rumination fully mediated the relationship between IU and depression. Despite the fact that in this study IU mediated the relationship between neuroticism and worry most strongly, IU also significantly mediated this relationship for all other symptom measures. These results are consistent with previous research finding significant associations with symptoms related to panic disorder (Carleton, Sharpe, et al., 2007; Dugas et al., 2001), social phobia (Boelen & Reijntjes, 2009; Carleton et al., 2010; Riskind et al., 2007), OCD (Holaway et al., 2006; Lind & Boschen, 2009; Tolin et al., 2003), and depression (de Jong-Meyer et al., 2009; Dugas et al., 2004; van der Heiden et al., 2010). Importantly, some of these previous studies have found that IU is uniquely associated with symptom measures even after controlling for other factors theoretically posited to also contribute to symptoms, such as metacognitions, cognitive avoidance, negative problem orientation, fear of negative evaluation, perfectionism, responsibility appraisals, anxiety sensitivity, positive and negative affectivity, self-esteem, and other symptom measures. Notwithstanding these findings, it is important for future studies to examine the degree to which IU explains unique variance in symptoms across the internalizing disorders, above and beyond other maintaining factors articulated in diagnosis-specific and indeed transdiagnostic models. For instance, it may be that

542

McEvoy & Mahoney

tion effects on the strength of associations. Third, our sample was highly comorbid, which may have resulted in us identifying associations not found in Dugas et al.'s diagnostically pure sample. It is arguable that the high level of comorbidity in our sample is more typical of real-world clinics and thus our findings more generalizable to clinical populations. de Jong-Meyer et al.'s sample comprised of dysphoric individuals recruited by advertisements and no diagnostic information was reported, and Sexton et al. used an unselected sample of undergraduate students. Fourth, rather than using a total score, we examined the relationship between different aspects of IU and symptoms (prospective and inhibitory anxiety), which may have increased our chances of detecting an effect. Thus, it appears that in large, comorbid treatment-seeking samples, IU may be more strongly related to a broader array of symptoms. However, it is possible that if we had included a measure of AS in our model, IU would no longer mediate the relationship between neuroticism and panic symptoms. There are several limitations to this study that must be considered. First, the mediation effect through IU explained a relatively small proportion of variance in all symptom measures. Therefore, although IU should be targeted in treatment when indicated, IU is likely to be only one of many important maintaining factors. Future research should include a broader array of proposed maintaining factors to better understand the relative contribution of, and interactions with, IU across emotional disorders. Second, given that this data was cross-sectional, no causal conclusions can be made. However, experimental research demonstrating that IU reliably contributes to worry increases our confidence in the possibility of a causal relationship (Buhr & Dugas, 2009; Ladouceur et al., 1997, 2000; Rosen & Knuper, 2009). It is important for future experimental and intervention studies to demonstrate that IU exacerbates symptoms, and that increasing tolerance for uncertainty ameliorates symptoms, across emotional disorders. It is also likely that the relationship between IU and symptoms is reciprocal, which is another avenue for future empirical evaluation. Third, structured diagnostic assessments were not completed by all participants, which may have resulted in the inclusion of individuals who did not meet criteria for an anxiety or depressive disorder. However, given the high level of symptoms and comorbidity in the subsample that completed the CIDI-Auto, it is likely that almost all participants would have met criteria for at least one disorder. Notwithstanding these limitations, the findings of this study have several important theoretical and treatment implications. First, IU is emerging as a

the variance explained by IU in the BSQ and ACQ here is better explained by a combination of other constructs in well-established models of panic disorder, such as anxiety sensitivity, catastrophic misinterpretations of physical sensations, coping selfefficacy, avoidance, and the use of safety-seeking behaviors (e.g., Casey, Oei, & Newcombe, 2004; Clark, 1986). Another avenue for future research is to investigate IU in relation to areas of core concern across diagnoses, rather than as a trait variable. Carleton, Sharpe, et al. (2007) speculated that the association between anxiety sensitivity and IU may be an intolerance of uncertainty regarding the meaning of physical symptoms of anxiety. For instance, it may be that individuals with PD/A are particularly intolerant of the possibility that an increase in their heart rate might signal an impending heart attack, and that this specific vulnerability might be more strongly related to panic symptoms than trait IU. Likewise, an individual with social phobia may be particularly intolerant of uncertainty about potential social catastrophes. If IU were assessed in relation to diagnosis-specific fears, then the associations may be stronger than those found in this study. In contrast to our findings, several studies have found evidence against a strong unique association between panic disorder symptoms and the IUS. In a sample with noncomorbid panic disorder, Dugas et al. (2005) found that IU was not significantly associated with the same measures of panic symptoms that were used in this study. Likewise, de Jong-Meyer et al. (2009) found that IU and metacognitions were associated with worry but not with panic sensations, as measured by the BAI. The BAI is predominantly a measure of somatic symptoms of anxiety that has been found to be more strongly related to panic disorder than other anxiety disorders (Cox, Cohen, Direnfeld, & Swinson, 1996). Consistent with our findings, Sexton et al. (2003) found that IU mediated the relationship between neuroticism and worry and that neuroticism had a direct relationship with OCD, panic, and worry. In contrast to our findings, however, IU did not mediate the relationship for either OCD or panic symptoms. There are a few potential explanations for the discrepancy between these findings and our results. First, Dugas et al.'s (2005), de Jong-Meyer et al.'s (2009), and Sexton et al.'s (2003) studies had substantially smaller sample sizes (N = 45, 71, and 91, respectively), thus having considerably less power to detect true associations than the current study did (n = 319). Second, having a larger sample may have reduced the influence of range attenua-

intolerance of uncertainty mediates symptoms

probable transdiagnostic maintaining factor for symptoms of various anxiety and depressive disorders. While our findings provide support for the IUM as it relates to GAD, this model may also provide explanatory power for other disorders. As such, existing diagnosis-specific and transdiagnostic models of internalizing disorders may need to more clearly articulate how IU interacts with other proposed maintaining mechanisms. Second, our findings provide some indication of the relative contribution of IU across the disorders, which could facilitate treatment matching. For instance, CBT with the goal of increasing tolerance of uncertainty should be a core feature of treatments for GAD (e.g., see Dugas et al., 2010; Ladouceur et al., 2000). Likewise, our results suggest that IU should be targeted in treatments for all other anxiety disorders and depression, although it may occupy a smaller proportion of therapeutic time. It is important to recognize that worry can be a feature of any internalizing disorder and that, as in the present sample, the diagnosis of GAD is common in treatment-seeking populations. Thus, clinicians would be well served to fully assess IU in any individual presenting with elevated levels of worry, and consider including it as an important maintaining mechanism in the case formulation. Future research investigating the relationship between IU and other forms of RNT (e.g., depressive rumination, postevent processing) would be informative. A recently developed transdiagnostic measure of RNT (McEvoy et al., 2010) that was demonstrated to have unique associations with a broad array of emotions (anxiety, depression, anger, shame, general distress) may be useful to further investigate transdiagnostic relationships between RNT and IU. Finally, treatment may also be informed by the finding that intolerance of prospective uncertainty partially mediated the relationship between neuroticism and symptoms associated with GAD and OCD, whereas inhibition in the face of uncertainty partially mediated this relationship for symptoms of social anxiety, PD/A, and depression. Specifically, it might be most important to increase tolerance to future uncertainty for GAD and OCD, perhaps with strategies such as focusing attention on the here and now rather than future-oriented worry, with the explicit intention to accept and expose oneself to future unpredictability (e.g., take a wait and see approach). In contrast, the focus for the phobic disorders and depression might be on action in the face of uncertainty, by reducing actions that prevent exposure to uncertainty (e.g., ceasing the use of avoidance and safety-seeking behaviors) and actively engaging in actions that directly confront uncertainty (e.g., increasing engagement in sponta-

543

neous activities). Such strategies, in conjunction with a rationale for increasing tolerance of uncertainty, could be easily incorporated into existing CBT protocols. Evidence that IU is a transdiagnostic maintaining factor is accumulating. Consistent with this body of research, our study demonstrated that different aspects of IU mediated the relationship between neuroticism and a broad array of disorder-related symptoms in a treatment-seeking sample. Future research simultaneously testing multiple theoretically prescribed mediators across the internalizing disorders would be useful to identify the relative contributions of each one to various manifestations of psychopathology. If IU continues to explain unique variance in symptoms across the anxiety and depressive disorders in such models, it would be confirmed as a robust transdiagnostic maintaining factor. It is conceivable that, together with research on other transdiagnostic mechanisms, these findings could guide the development of a transdiagnostic treatment protocol that efficiently and effectively impacts on symptoms of primary and comorbid conditions.
References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Andrews, G., & Peters, L. (1998). The psychometric properties of the Composite International Diagnostic Interview. Social Psychiatry and Psychiatric Epidemiology, 33, 8088. Baron, R. M., & Kenny, D. A. (1986). The moderatormediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 6, 11731182. Barrett, P. T., Petrides, K. V., Eysenck, S. B. G., & Eysenck, H. J. (1998). The Eysenck Personality Questionnaire: An examination of the factorial similarity of P, E, N, and L across 34 countries. Personality and Individual Differences, 25, 805819. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II manual. New York: Harcourt Brace Janovich. Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23, 10111023. Berenbaum, H., Bredemeier, K., & Thompson, R. J. (2008). Intolerance of uncertainty: Exploring its dimensionality and associations with need for cognitive closure, psychopathology, and personality. Journal of Anxiety Disorders, 22, 117125. Boelen, P. A., & Reijntjes, A. (2009). Intolerance of uncertainty and social anxiety. Journal of Anxiety Disorders, 29, 130135. Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30, 3337.

544

McEvoy & Mahoney

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. Behavior Therapy, 41, 4658. 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, 215226. Dugas, M. J., Gosselin, P., & Ladouceur, R. (2001). Intolerance of uncertainty and worry: Investigating specificity in a nonclinical sample. Cognitive Therapy and Research, 25, 551558. Dugas, M. J., & Ladouceur, R. (2000). Treatment of GAD: Targeting intolerance of uncertainty in two types of worry. Behavior Modification, 24, 635657. Dugas, M. J., Ladouceur, R., Lger, E., Freeston, M. H., Langlois, F., Provencher, M., . . ., & Boisvert, J. (2003). Group cognitive behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology, 71, 821825. Dugas, M. J., Letarte, H., Rhaume, J., Freeston, M. H., & Ladouceur, R. (1995). Worry and problem solving: Evidence of a specific relationship. Cognitive Therapy and Research, 19, 109120. Dugas, M. J., Marchand, A., & Ladouceur, R. (2005). Further validation of a cognitive-behavioral model of generalized anxiety disorder: Diagnostic and symptom specificity. Journal of Anxiety Disorders, 19, 329343. Dugas, M. J., Schwartz, A., & Francis, K. (2004). Intolerance of uncertainty, worry, and depression. Cognitive Therapy and Research, 28, 835842. Dugas, M. J., Sevard, P., Gaudet, A., Turcotte, J., Laugesen, N., Robichaud, M., . . ., & Koerner, N. (2007). Can the components of a cognitive model predict the severity of generalized anxiety disorder? Behavior Therapy, 38, 169178. Ehring, T., & Watkins, E. R. (2008). Repetitive negative thinking as a transdiagnostic process. International Journal of Cognitive Therapy, 1, 192205. Eysenck, H. J., & Eysenck, S. B. G. (1975). Manual of the Eysenck Personality Questionnaire. London: Hodder & Stoughton. Freeston, M. H., Rhaume, J., Letarte, H., Dugas, M. J., & Ladouceur, R. (1994). Why do people worry? Personality and Individual Differences, 17, 791802. Gillis, M. M., Haaga, D. A. F., & Ford, G. T. (1995). Normative values for the Beck Anxiety Inventory, Fear Questionnaire, Penn State Worry Questionnaire, and Social Phobia and Anxiety Inventory. Psychological Assessment, 7, 450455. Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford: Oxford University Press. Holaway, R. M., Heimberg, R. G., & Coles, M. E. (2006). A comparison of intolerance of uncertainty in analogue obsessive-compulsive disorder and generalized anxiety disorder. Journal of Anxiety Disorders, 20, 158174. Jnsdttir, S. D., & Smri, J. (2000). Measuring obsessions without worry: Convergent and discriminant validity of the revised Padua inventory in an Icelandic student population. Scandinavian Journal of Behaviour Therapy, 29, 4956. Koerner, N., & Dugas, M. J. (2008). An investigation of appraisals in individuals vulnerable to excessive worry: The role of intolerance of uncertainty. Cognitive Therapy and Research, 32, 619638.

Buhr, K., & Dugas, M. J. (2002). The Intolerance of Uncertainty Scale: Psychometric properties of the English version. Behaviour Research and Therapy, 40, 931945. Buhr, K., & Dugas, M. J. (2006). Investigating the construct validity of intolerance of uncertainty and its unique relationship with worry. Journal of Anxiety Disorders, 20, 222236. Buhr, K., & Dugas, M. J. (2009). The role of fear of anxiety and intolerance of uncertainty in worry: An experimental manipulation. Behaviour Research and Therapy, 47, 215223. Burns, G. L. (1995). Padua InventoryWashington State University Revision. Pullman, WA: Author. Burns, G. L., Keortge, S., Formea, G., & Sternberger, L. (1996). Revision of the Padua Inventory of obsessivecompulsive disorder symptoms: Distinctions between worry, obsessions, and compulsions. Behaviour Research and Therapy, 34, 163173. Butzer, B., & Kuiper, N. A. (2006). Relationships between the frequency of social comparisons and self-concept clarity, intolerance of uncertainty, anxiety, and depression. Personality and Individual Differences, 41, 167176. Carleton, R. N., Collimore, K. C., & Asmundson, G. (2010). It's not just the judgmentsIt's that I don't know: Intolerance of uncertainty as a predictor of social anxiety. Journal of Anxiety Disorders, 24, 189195. 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, 105117. 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, 23072316. Caruso, J. C., Witkiewitz, K., Belcourt-Dittloff, A., & Gottlieb, J. D. (2001). Reliability of scores from the Eysenck Personality Questionnaire: A reliability generalization study. Educational and Psychological Measurement, 61, 675689. Casey, L. M., Oei, T. P. S., & Newcombe, P. A. (2004). An integrated cognitive model of panic disorder: The role of positive and negative cognitions. Clinical Psychology Review, 24, 529555. Chambless, D. L., Beck, A. T., Gracely, E. J., & Grisham, J. R. (2000). Relationship of cognitions to fear of somatic symptoms: A test of the cognitive theory of panic. Depression and Anxiety, 11, 19. Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 10901097. Chambless, D. L., & Gracely, E. J. (1989). Fear of fear and the anxiety disorders. Cognitive Therapy and Research, 13, 920. Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461470. Cox, B. J., Cohen, E., Direnfeld, D. M., & Swinson, R. P. (1996). Does the Beck Anxiety Inventory measure anything beyond panic attack symptoms? Behaviour Research and Therapy, 34, 949954. Cox, B. J., Ross, L., Swinson, R. P., & Direnfeld, D. M. (1998). A comparison of social phobia outcome measures in cognitivebehavioral therapy. Behavior Modification, 22, 285297. de Jong-Meyer, R., Beck, B., & Riede, K. (2009). Relationships between rumination, worry, intolerance of uncertainty and metacognitive beliefs. Personality and Individual Differences, 46, 547551. Dozois, D. J. A., Dobson, K. S., & Ahnberg, J. L. (1998). A psychometric evaluation of the Beck Depression InventoryII. Psychological Assessment, 10, 8389.

intolerance of uncertainty mediates symptoms

Ladouceur, R., Blais, F., Freeston, M. H., & Dugas, M. J. (1998). Problem solving and problem orientation in generalized anxiety disorder. Journal of Anxiety Disorders, 12, 139152. Ladouceur, R., Gosselin, P., & Dugas, M. J. (2000). Experimental manipulation of intolerance of uncertainty: A study of a theoretical model of worry. Behaviour Research and Therapy, 38, 933941. Ladouceur, R., Talbot, F., & Dugas, M. J. (1997). Behavioral expressions of intolerance of uncertainty in worry: Experimental findings. Behavior Modification, 21, 355371. Laugesen, N., Dugas, M. J., & Bukowski, W. M. (2003). Understanding adolescent worry: The application of a cognitive model. Journal of Abnormal Child Psychology, 31, 5564. Lind, C., & Boschen, M. J. (2009). Intolerance of uncertainty mediates the relationship between responsibility beliefs and compulsive checking. Journal of Anxiety Disorders, 23, 10471052. Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455470. Mattick, R. P., Peters, L., & Clarke, J. C. (1989). Exposure and cognitive restructuring for severe social phobia: A controlled study. Behavior Therapy, 20, 323. McEvoy, P. M., & Mahoney, A. E. J. (2011). Achieving certainty about the structure of intolerance of uncertainty in a treatmentseeking sample with anxiety and depression. Journal of Anxiety Disorders, 25, 112122. McEvoy, P. M., Mahoney, A. E. J., & Moulds, M. L. (2010). Are worry, rumination, and post-event processing one and the same? Development of the repetitive thinking questionnaire. Journal of Anxiety Disorders, 24, 509519. Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487495. Molina, S., & Borkovec, T. D. (1994). The Penn State Worry Questionnaire: Psychometric properties and associated characteristics. In G. C. L. Davey, & F. Tallis (Eds.). Worrying: Perspectives on theory, assessment and treatment (pp. 265283). New York: Wiley. Norton, P. (2005). A psychometric analysis of the Intolerance of Uncertainty Scale among four racial groups. Journal of Anxiety Disorders, 19, 699707. Osman, A., Kopper, B. A., Barrios, F., Gutierrez, P. M., & Bagge, C. L. (2004). Reliability and validity of the Beck Depression Inventory-II with adolescent psychiatric inpatients. Psychological Assessment, 16, 120132. Peters, L., & Andrews, G. (1995). Procedural validity or the computerized version of the Composite International Diagnostic Interview (CIDI-Auto) in the anxiety disorders. Psychological Medicine, 25, 12691280. Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple media-

545

tion models. Behaviour Research Methods, Instruments, and Computers, 36, 717731. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879891. Riskind, J. H., Tzur, D., Williams, N. L., Mann, B., & Shahar, G. (2007). Short-term predictive effects of the looming cognitive style on anxiety disorder symptoms under restrictive methodological conditions. Behaviour Research and Therapy, 45, 17651777. Rosen, N. O., & Knuper, B. (2009). A little uncertainty goes a long way: State and trait differences in uncertainty interact to increase information seeking but also increase worry. Health Communication, 24, 228238. Sexton, K. A., Norton, P. J., Walker, J. R., & Norton, G. R. (2003). Hierarchical model of generalized and specific vulnerabilities in anxiety. Cognitive Behaviour Therapy, 32, 8294. Starcevic, V., & Berle, D. (2006). Cognitive specificity of anxiety disorders: A review of selected key constructs. Depression and Anxiety, 23, 5161. Steketee, G., Frost, R. O., & Cohen, I. (1998). Beliefs in obsessive-compulsive disorder. Journal of Anxiety Disorders, 12, 525537. Tolin, D., Abramowitz, J. S., Brigidi, B. D., & Foa, E. B. (2003). Intolerance of uncertainty in obsessive-compulsive disorder. Journal of Anxiety Disorders, 17, 233242. 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 generalized anxiety disorder. Journal of Anxiety Disorders , 24 , 284289. van Rijsoort, S., Emmelkamp, P., & Vervaeke, G. (1999). The Penn State Worry Questionnaire and the Worry Domains Questionnaire: Structure, reliability and validity. Clinical Psychology and Psychotherapy, 6, 297307. Wittchen, H. -U. (1994). Reliability and validity studies of the WHO Composite International Diagnostic Interview (CIDI): A critical review. Journal of Psychiatric Research, 28, 5784. World Health Organization (1993). The ICD-I0 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva, Switzerland: Author. World Health Organization (1997). CIDI-auto version 2.1: Administrator's guide and reference. Sydney, Australia: Training and Reference Centre for WHO CIDI. Yook, K., Kim, K., Suh, S. Y., & Lee, K. S. (2010). Intolerance of uncertainty, worry, and rumination in major depressive disorder and generalized anxiety disorder. Journal of Anxiety Disorders, 24, 623628. R E C E I V E D : June 11, 2010 A C C E P T E D : February 23, 2011 Available online 6 June 2011