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Cognitive Behaviour Therapy

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Trait Versus Situation-Specific Intolerance of Uncertainty in a Clinical Sample with Anxiety and Depressive Disorders
Alison E. J. Mahoney & Peter M. McEvoy
a a b c

Clinical Research Unit for Anxiety and Depression, St Vincent's Hospital, Sydney, Australia
b c

Centre for Clinical Interventions, Perth, Australia

School of Psychology, University of Western Australia, Perth, Australia Version of record first published: 28 Oct 2011.

To cite this article: Alison E. J. Mahoney & Peter M. McEvoy (2012): Trait Versus Situation-Specific Intolerance of Uncertainty in a Clinical Sample with Anxiety and Depressive Disorders, Cognitive Behaviour Therapy, 41:1, 26-39 To link to this article: http://dx.doi.org/10.1080/16506073.2011.622131

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Cognitive Behaviour Therapy Vol 41, No 1, pp. 2639, 2012

Trait Versus Situation-Specic Intolerance of Uncertainty in a Clinical Sample with Anxiety and Depressive Disorders
Alison E. J. Mahoney1 and Peter M. McEvoy2,3
Clinical Research Unit for Anxiety and Depression, St Vincents Hospital, Sydney, Australia; 2Centre for Clinical Interventions, Perth, Australia; 3School of Psychology, University of Western Australia, Perth, Australia
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Abstract. Intolerance of uncertainty (IU) has been most heavily implicated in the development and maintenance of generalised anxiety disorder; however, recent research has supported the transdiagnostic conceptualisation of IU by demonstrating that IU contributes to a broad array of symptoms associated with multiple anxiety and depressive disorders. The aim of this study was to examine IU rstly as a trait variable and secondly in reference to a regularly occurring, diagnostically relevant situation in a large clinical sample (N 218). A measure of situation-specic IU (the Intolerance of Uncertainty Scale Situation-Specic Version; IUS-SS) is presented. The IUS-SS was found to have a unitary factor structure and high internal consistency. Participants reported signicantly more situation-specic IU compared to trait IU. Discriminant validity was indicated by lack of signicant relationships with measures of extraversion and alcohol use. Supporting the convergent validity and transdiagnostic nature of the scale, the IUS-SS was positively associated with neuroticism and symptoms of generalised anxiety disorder and social phobia, and explained unique variance in symptoms of depression and panic disorder above and beyond trait IU. Theoretical and clinical implications are discussed. Key words: intolerance of uncertainty; transdiagnostic; anxiety; depression; cognitive behaviour therapy Received 2 February, 2011; Accepted 18 August, 2011 Correspondence address: Alison E. J. Mahoney, Clinical Research Unit for Anxiety and Depression, St Vincents Hospital, Level 4 OBrien Centre, 394-404 Victoria Street, Darlinghurst, Sydney, New South Wales 2010, Australia. Tel: 612 8382 1407. Fax: 612 8382 1402. E-mail: amahoney@ stvincents.com.au
1

Introduction
Individuals who are intolerant of uncertainty appraise uncertain or ambiguous situations as threatening and typically respond negatively to them on a cognitive, emotional, and behavioural level (Dugas, Buhr, & Ladouceur, 2004). Previous research has tended to examine intolerance of uncertainty (IU) within specic internalising disorders, with the majority of studies focussing on the role of IU in excessive worry and generalised anxiety disorder (Dugas, Gagnon, Ladouceur, & Freeston, 1998; Sexton, Norton, Walker, & Norton, 2003; van de Heiden et al., 2010).
http://dx.doi.org/10.1080/16506073.2011.622131

Evidence is accumulating that IU contributes to the symptoms of multiple internalising disorders, and thus may be better understood as a transdiagnostic construct (McEvoy & Mahoney, 2011; Starcevic & Berle, 2006). IU has been shown to predict symptoms of obsessive compulsive disorder (OCD; Steketee, Frost, & Cohen., 1998), social phobia (Boelen & Reijntjes, 2009; Carleton, Collimore, & Asmundson, 2010), depression (de Jong-Meyer, Beck, & Riede, 2009; Miranda, Fontes, & Marroqu n, 2008), panic disorder, and agoraphobia (McEvoy & Mahoney, 2011). In a recent meta-analysis of 58 studies, Gentes and Ruscio (2011) found that IU was

q 2012 Swedish Association for Behaviour Therapy ISSN 1650-6073

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signicantly associated with symptoms of generalised anxiety disorder (GAD), major depressive disorder (MDD), and OCD. Additionally, reductions in IU reportedly precede or occur concurrently with symptom reduction during cognitive behavioural therapy for GAD (Dugas & Ladouceur, 2000; Dugas et al., 2003) and OCD (Overton & Menzies, 2005). Preliminary data also suggest that IU-based treatments may signicantly reduce symptoms of social phobia (Hewitt, Egan, & Rees, 2009) and hypochondriasis (Langlois & Ladouceur, 2004). Thus, IU appears to be associated with a broad range of emotional disorders. Existing research examines IU as a trait or trans-situational variable. That is, IU has previously been explored as a general tendency to appraise and respond to uncertain situations in particular ways, for example, general beliefs such as uncertainty makes me uneasy, anxious, or stressed or when its time to act uncertainty paralyses me (Buhr & Dugas, 2002). An additional avenue of investigation is the potential difference between trait IU and IU that is associated with specic situations that distress people with emotional disorders (e.g., uncertainty about the cause of physical symptoms of anxiety for panic disorder or uncertainty about the meaning of ambiguous social cues for those with social phobia). Tolin, Abramowitz, Brigidi, and Foa (2003) suggested that general experiences of uncertainty may or may not reect how anxious patients feel about uncertainty associated with specic situations that cause them distress. Tolin et al. (2003) were writing in reference to OCD; however, Carleton et al. (2010) made a similar point about those with social phobia. They speculated that the degree to which people with social phobia can tolerate uncertainty associated with social situations may affect their level of social anxiety. The question arises, how strongly is IU associated with symptoms of emotional disorders when we examine IU specically in relation to areas of primary clinical concern? It is possible that the relevance of IU may be most apparent when we examine it in relation to areas of core concern for patients. Previous research has typically examined IU as a unitary construct; however, recent research has found that certain components of IU are differentially associated with

symptoms of internalising disorders (Carleton et al., 2010; McEvoy & Mahoney, 2011). Carleton, Norton, and Asmundson (2007) identied two factors within IU, namely, prospective anxiety and inhibitory anxiety. Prospective anxiety relates to fear and anxiety in anticipation of uncertainty, whereas inhibitory anxiety relates to inaction in the face of uncertainty. In a treatment-seeking sample, McEvoy and Mahoney (2011) found that prospective anxiety was uniquely associated with symptoms of GAD and OCD, whereas inhibitory anxiety was uniquely associated with symptoms relating to social phobia, panic disorder, agoraphobia, and depression. Given that the prospective and inhibitory anxiety scales were uniquely associated with both anxiety and depression, McEvoy and Mahoney (2011) suggested that these factors be relabelled prospective and inhibitory IU. This relabeling was subsequently supported by the authors of the IUS-12 (R. N. Carleton, personal communication, January 11, 2011). McEvoy and Mahoney (in press) further demonstrated that prospective IU (P-IU) partially mediated the relationship between neuroticism and symptoms of GAD and OCD, whereas inhibitory IU (I-IU) partially mediated the relationship between neuroticism and symptoms of social phobia, panic disorder, agoraphobia, and depression, even when controlling for symptoms of other internalising disorders. It is noteworthy that the meditational pathway explained a higher proportion of variance in GAD symptoms (i.e., worry) than symptoms of the other disorders. In a community sample, Carleton et al. (2010) also found that I-IU, but not P-IU, was uniquely associated with social anxiety symptoms. This study sought to examine whether different components of IU, namely, P-IU and I-IU, were also evident within the construct of situation-specic IU. The aim of this study was to develop a measure of IU that indexed IU in relation to diagnostically pertinent situations: the Intolerance of Uncertainty Scale SituationSpecic version (IUS-SS). In order to examine the psychometric properties of the IUS-SS and draw comparisons between trait and situation-specic IU, we sought to examine (a) the factor structure of the IUS-SS, (b) the instruments internal reliability and norms, (c) gender differences, and (d) relationships

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between the IUS-SS and measures of personality dimensions, alcohol use, and symptoms of anxiety and depressive disorders. First, we hypothesised that the factor structure of the IUS-SS would replicate previous ndings (Carleton et al., 2007; McEvoy & Mahoney, 2011) and comprise two factors: P-IU and IIU. We also predicted that the IUS-SS will be internally reliable. Second, we hypothesised that situation-specic IU would be positively correlated with trait IU and neuroticism, thus providing evidence for the scales convergent validity. We also expected that the IUS-SS would demonstrate acceptable discriminant validity as indicated by a lack of relationships with measures of extraversion and alcohol use. Previous studies have shown a lack of relationship between trait IU and extraversion (Berenbaum, Bredemeier, & Thompson, 2008; McEvoy & Mahoney, 2011), and although it is plausible that IU is associated with alcohol use, this association was expected to be substantially weaker than the hypothesised associations with symptoms of emotional disorders. Third, we expected that participants would report more situationspecic IU compared to trait IU. Lastly, we hypothesised that, consistent with studies of trait IU (McEvoy & Mahoney, 2011), situation-specic IU would explain unique variance in symptoms of anxiety and depressive disorders.

majority of the sample experienced comorbid disorders; 23% of the sample met criteria for one diagnosis, 31% with two diagnoses, 26% with three diagnoses, 13% with four diagnoses, 6% with ve diagnoses, and 1% met criteria for six diagnoses. Comorbid diagnoses included GAD (28%), social phobia (18%), OCD (8%), panic disorder with or without agoraphobia (7%), depressive disorder (40%), alcohol use disorder (13%), and drug use disorder (4%).

Measures
Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). The ADIS-IV (Brown et al., 1994) is a structured diagnostic interview for the anxiety, mood, somatoform, and substance use disorders according to criteria in DSM-IV (American Psychiatric Association, 1994). Brown, Di Nardo, Lehman, and Campbell (2001) provide evidence of good inter-rater reliability for the anxiety disorders investigated in the present study (k .65 .79). Inter-rater reliability (k .63) for the combined depressive disorders group (MDD and dysthymia) was also acceptable (Brown et al., 2001). Evidence of construct validity, including discriminant and convergent validity, has been demonstrated (Brown, Chorpita, & Barlow, 1998). Diagnosticians in this study were four clinical psychologists and four psychiatric registrars. Training involved (a) thorough reading of the ADIS-IV protocol, (b) observation of an experienced interviewer conducting an ADIS-IV, and (c) administration of an ADIS-IV while being observed by an experienced interviewer. After the training interviews, diagnosticians compared and reviewed diagnoses. All clinicians had extensive experience in the assessment and treatment of internalising disorders. Principal diagnoses were determined collaboratively by assessing clinicians and participants as the most distressing and life-interfering disorder at the time of interview. Intolerance of Uncertainty Scale-12 (IUS-12). The 12-item IUS-12 (Carleton et al., 2007) was our trait measure of IU and consists of two subscales: prospective IU (P-IU) and inhibitory IU (I-IU). P-IU assesses anxiety in anticipation of uncertainty (e.g., One should always look ahead so as to avoid surprises), whereas I-IU measures inhibition of action or experience (e.g., The smallest doubt can stop me from

Method
Participants
Participants (N 218 and 51% women) were recruited from a specialist anxiety disorders treatment service. Participants had a mean age of 35.73 years (SD 11.59) and 73% had completed high school. Regarding relationship status, 32% reported that they were married or were in de facto relationships, 59% were never married, 9% were separated or divorced, and 1% were widowed. Prior to treatment, participants completed the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994). The principal diagnoses of the sample included social phobia (45%), GAD (19%), panic disorder with or without agoraphobia (19%), OCD (7%), MDD (5%), dysthymic disorder (1%), specic phobia (2%), posttraumatic stress disorder (2%), and somatisation disorder (1%). The

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acting). Evidence of internal consistency (a .91 for total score), convergent validity, discriminant validity, and factorial stability has been demonstrated (Carleton et al., 2007; McEvoy & Mahoney, 2011). In this study, the IUS-12 demonstrated acceptable levels of skewness (total score 2 .26, P-IU 2 .24, I-IU 2 .23), kurtosis (total score 2 .49, P-IU 2 .56, IIU 2 .56), and internal consistency (IUS-12 total a .94, average inter-item correlation .55; P-IU a .91, average inter-item correlation .58; I-IU a .88, average inter-item correlation .59). Intolerance of Uncertainty Scale SituationSpecific Version (IUS-SS). The 12-item IUSSS is an adaptation of the IUS-12 and was developed for the purposes of this study in order to examine IU in relation to specic situations that were diagnostically pertinent to the sampled anxiety disorders. When completing the IUS-SS, participants selected their area of primary concern from a list (e.g., social interactions or performance situations, places or situations that may lead to panic sensations, excessive worries about everyday concerns, or intrusive distressing thoughts that lead to repetitive behaviours), and then described a situation related to this concern that was regularly occurring and distressing (e.g., conversations with a colleague, catching trains, watching the evening news, or touching door knobs). The items from the IUS-12 were then completed in reference to that situation (item wording was altered to reference the situation, e.g., the IUS-12 item I cant stand being taken by surprise became I cant stand being taken by surprise in this situation). Penn State Worry Questionnaire (PSWQ). The PSWQ (Meyer, Miller, Metzger, & Borkovec, 1990) is a 16-item measure of worry, which is the core symptom of GAD. The PSWQ has good internal consistency (a .86.95) and temporal stability (r .92 over 810 weeks and r .74.93 over 4 weeks; Meyer et al., 1990; Molina & Borkovec, 1994). Evidence of construct validity, including discriminant and convergent validity, has been demonstrated in clinical and community populations (e.g., Brown, Antony, & Barlow, 1992; Meyer et al., 1990; van Rijsoort, Emmelkamp, & Vervaeke, 1999). In this sample, levels of skewness (2 .74), kutosis (2 .10), and internal consistency (a .77, average inter-item correlation .32) were acceptable.

Body Sensations Questionnaire (BSQ) and Agoraphobic Cognitions Questionnaire (ACQ). The 17-item BSQ and 14-item ACQ (Chambless, Caputo, Bright, & Gallagher, 1984) are established measures of panic disorder and agoraphobia symptoms. The scales measure physical sensations and thoughts respondents typically experience when they are nervous or frightened. Internal consistency is good (a .80 and .87 for ACQ and BSQ, respectively), and evidence of temporal stability (r .86 and .67 for ACQ and BSQ, respectively, over 31 days) and construct validity has been provided (Chambless et al., 1984; Chambless, Beck, Gracely, & Grisham, 2000; Chambless & Gracely, 1989). In the current study, levels of skewness (ACQ .88 and BSQ .41), kutosis (ACQ .58 and BSQ 2 .55), and internal consistency were acceptable (ACQ a .86 and average inter-item correlation .30; BSQ a .94 and average inter-item correlation .46). Social Interaction Phobia Scale (SIPS). The SIPS (Carleton et al., 2009) is a 14-item measure of social phobia symptoms, specically social interaction anxiety, fear of overt evaluation, and fear of attracting attention. The SIPS items were derived from factor analyses of the Social Phobia Scale and Social Interaction Anxiety Scale (Mattick & Clarke, 1998). Internal consistency in clinical and undergraduate samples is high (a .92), and evidence of factorial stability, convergent validity, and discriminant validity has been provided (Carleton et al., 2009). In this study, the total score was employed rather than subscale scores in order to be consistent with previous research (Carleton et al., 2010). Current skew was 2 .24 and kurtosis was 2 .87. Current internal reliability a .94 (average inter-item correlation .52). Padua Inventory Washington State University Revision (PI). The PI (Burns, 1995) is a widely used 39-item self-report measure of OCD symptoms (e.g., I feel my hands are dirty when I touch money). Evidence for convergent and discriminant validity, as well as factor structure, has been demonstrated (Burns, Keortge, Formea, & Sternberger, nsdo ttir & Sma ri, 2000). Internal 1996; Jo consistency (a .92) and temporal stability ( r .61 .84 across subscales over 6 7 months) are good (Burns et al., 1996). In this study, the total score was used and a was .93 (average inter-tem correlation .25). Skew

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was 1.05 and kurtosis was .59; however, a square-root transformation reduced these values to .18 and 2 .44, respectively. All subsequent analyses were conducted with the transformed variable (PIsqrt). Beck Depression Inventory (BDI-II). The BDI-II (Beck, Steer, & Brown, 1996) is a 21item measure of depression symptoms experienced during the previous fortnight. Internal consistency ( a .92) and test retest 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). Support for convergent and discriminant validity has also been reported (Osman et al., 1997; Steer, Ball, Ranieri, & Beck, 1997). In this study, skewness (2 .06), kutosis (2 .78), and internal reliability (a .94, average inter-item correlation was .41) were acceptable. Eysenck Personality Questionnaire (EPQ). The 23-item neuroticism subscale (EPQ-N) and 21-item extraversion subscale (EPQ-E) of the EPQ were used (Eysenck & Eysenck, 1975). Internal consistency (a .82 for both subscales; Loo, 1979) and test retest reliability (r .82 and .92 over 1 month for neuroticism and extraversion, respectively; Eysenck & Eysenck, 1975) are good, and data demonstrating construct validity, including convergent and discriminant validity, are extensive (e.g., Barrett, Petrides, Eysenck, & Eysenck, 1998; Caruso, Witkiewitz, BelcourtDittloff, & Gottlieb, 2001; Steele & Kelly, 1976). In this study, skew was 2 1.09 and .66 and kurtosis was .92 and 2 .15 for the EPQ-N and EPQ-E, respectively. Internal consistencies were a .84 (average inter-item correlation .19) and a .76 (average inter-item correlation .23) for neuroticism and extraversion, respectively. Alcohol Use Disorders Identification Test. The 10-item AUDIT (Saunders, Aasland, Babor, de le Fuente, & Grant, 1993) is a widely used screening measure that identies hazardous and harmful alcohol consumption. Evidence of internal consistency (a .75 .94), convergent validity, and discriminant validity is extensive (Allen, Litten, Fertig, & Babor, 1997). Internal consistency was a .88 in this sample (average inter-item correlation .45). Levels of skewness (1.80) and kurtosis (3.38) were problematic; however, a square-root

transformation reduced these values to .45 and 2 .19, respectively. All subsequent analyses were conducted with the transformed variable (AUDITsqrt).

Procedure
Participants completed the ADIS-IV and a battery of questionnaires (including the IUS12, IUS-SS, PSWQ, ACQ, BSQ, SIPS, PI, BDI-II, EPQ-N, EPQ-E, and AUDIT) prior to treatment at a specialist anxiety disorders clinic. Participants consented for their data to be used for research purposes. The use of the data was approved by the Hospitals Human Research Ethics Committee.

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Results
Situations reported in the IUS-SS
The majority of the sample (n 187) completed the IUS-SS; 159 participants described a situation that matched their principal diagnosis and 20 described a situation that matched a comorbid diagnosis. A match was dened as a situation or experience that appeared or was likely to appear as an item on the relevant symptom measure described above (e.g., mixing in a group from the SIPS). When the relevance of situations was unclear, qualitative data from participants ADIS-IV responses were consulted. A small number of participants (n 5) did not complete a description, and three participants described recent nancial or relationship stressors that were unrelated to their diagnoses. Situations were coded by one researcher (AM), although a subsample (n 106) was coded by an additional clinical psychologist as a measure of reliability. Agreement between coders was good (k .64) and discrepancies were resolved via discussion and consensus. Participants who completed the IUS-SS were not signicantly different from non-completers with respect to age, gender, number of diagnoses, or IUS-12 total score (all ps . .05).

IUS-SS factor analysis

Table 1 shows the means, standard deviations, skewness, kurtosis, and corrected item-total correlations for each item of the IUS-SS. Common factor analysis (i.e., principal axis factor analysis) was used to analyse the 12 IUS-SS items. Oblique rotation was used because if multiple factors were derived it was

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Table 1. Factor loadings, means, standard deviations, skewness, kurtosis and corrected item-total correlations (CITC) for the IUS-SS items Factor loadings .81 .81 .80 .79 .78 .74 .73 .72 .72 .70 .68 .61

Item 1. I always want to know what the future has in store for me for this situation 2. Unforeseen events associated with this situation upset me greatly 3. I cant stand being taken by surprise in this situation 4. The smallest doubt can stop me from acting in this situation 5. A small unforeseen event in this situation can spoil everything, even with the best planning 6. When I am uncertain I cant function very well in this situation 7. One should always look ahead so as to avoid surprises in this situation 8. When its time to act, uncertainty will paralyse me in this situation 9. I should be able to organise everything in advance for this situation 10. I must get away from all uncertainty in this situation 11. It frustrates me not having all the information I need about this situation 12. Uncertainty in this situation keeps me from living a full life Total

M 3.23 3.43 3.32 3.28 3.28 3.49 3.24 3.02 3.04 3.09 3.07 3.65

SD 1.31 1.33 1.40 1.40 1.37 1.22 1.32 1.40 1.36 1.29 1.37 1.25

Skewness 2 .38 2 .57 2 .51 2 .55 2 .42 2 .54 2 .35 2 .21 2 .24 2 .23 2 .25 2 .75 2 .45

Kurtosis 2 .56 2 .45 2 .77 2 .56 2 .84 2 .22 2 .79 2 .99 2 .98 2 .87 2 .84 2 .18 2 .25

CITC .77 .77 .77 .77 .75 .72 .71 .70 .69 .67 .66 .60 1.00

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39.15 12.27

expected that they would be correlated with one another. Common factor analysis was used because estimates tend to replicate better with conrmatory factor analysis and our intention was to examine relationships among manifest variables to latent variables (Floyd & Widaman, 1995). The highest bivariate correlation between items was .72, suggesting that item redundancy was not a signicant problem. Several methods of estimating the most appropriate number of factors were used. First, Velicers minimum average partial (MAP) and Horns parallel analysis (OConnor, 2000) were used because they have demonstrated robust estimations in the development of health measures in samples of 100 300 subjects (Coste, Fermanian, & Venot, 1995). In addition, the eigenvalues and Scree Test were examined. The MAP test, parallel analysis, and Scree plot indicated the presence of one factor with one eigenvalue greater than 1 (6.63). Consistent with previous research

(McEvoy & Mahoney 2011), criteria for removing items were if the factor loading did not exceed .40. Given the existence of only one factor, cross-loadings were not relevant. All items loaded above .40 (range .61 .81, see Table 1). The IU factor explained 55.23% of the variance.

IUS-SS descriptive statistics and internal consistency

Table 2 provides descriptive statistics for the IUS-SS and IUS-12. Participants reported signicantly more situation-specic IU than trait IU [t(167) 6.00, p , .001, h 2 .18]. IUS-SS internal consistency was excellent (a .94, average inter-item correlation .55). There were no signicant differences in IUS-SS mean for gender (men: M 38.77, SD 11.57; women: M 39.51, SD 12.95) [t(185) .41, p .68, h 2 .001]. The IUS-12 means also did not differ across gender (men: M 33.47,

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Table 2. Means and standard deviations for the IUSSS, IUS-12, personality dimensions, and symptom measures Symptom measure IUS-SS IUS-12 SIPS ACQ BSQ PSWQ PIsqrt BDI-II EPQ-N EPQ-E AUDITsqrt M 38.71 34.19 30.48 29.69 43.43 64.75 4.40 22.21 17.41 8.29 2.09 SD 12.34 12.59 14.64 10.21 16.35 11.12 2.06 11.97 4.53 4.12 1.41

those with the respective diagnosis compared to those without the diagnosis (all ps , .01).

IUS-SS convergent and divergent validity

We examined evidence of convergent validity for the IUS-SS via relationships with neuroticism in order to be consistent with previous studies in trait IU (McEvoy & Mahoney, 2011). Supporting convergent validity, there were signicant positive bivariate Pearson correlations between the IUS-SS and the IUS12 (r .69, p , .001) and the EPQ-N (r .46, p , .001). Evidence of divergent validity for the IUS-12 has been previously examined via relationships with extraversion (McEvoy & Mahoney, 2011). Similarly, we found evidence of divergent validity for the IUS-SS via a nonsignicant correlation between the IUS-SS and the EPQ-E (r 2 .14, p .08). The relationship between IU and alcohol use was used as an additional assessment of divergent validity. The IUS-SS and IUS-12 did not signicantly correlate with the AUDITsqrt (IUS-SS: r .01, p .94; IUS-12: r 2 .02, p .83).

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Note. IUS-SS, Intolerance of Uncertainty Scale Situation-Specic version; IUS-12, Intolerance of Uncertainty Scale-12; SIPS, Social Interaction Phobia Scale; ACQ, Agoraphobic Cognitions Questionnaire; BSQ, Body Sensations Questionnaire; PSWQ, Penn State Worry Questionnaire; PI, Padua Inventory; BDI-II, Beck Depression Inventory; EPQ-N, Eysenck Personality Questionnaire Neuroticism subscale; EPQ-E, Eysenck Personality Questionnaire Extraversion subscale; AUDIT, Alcohol Use Disorders Identication Test.

SD 11.67; women: M 35.35, SD 13.25) [t (197) 1.06, p .29, h 2 .01].

Descriptive statistics for personality and symptom measures

Table 2 presents the means and standard deviations for the personality dimensions and symptom measures. Independent samples t tests were conducted to compare mean scores on symptom measures for participants with and without each diagnosis. For all symptom measures, scores were signicantly higher for

Transdiagnostic associations between IU and symptoms

Bivariate Pearson correlation coefcients indicated the strength of associations between IU and symptom measures across the entire sample regardless of diagnosis (see Table 3). To reduce the number of analyses, a composite index was calculated for panic disorder and agoraphobic symptoms (BSQ ACQ/2). The BSQ and ACQ were correlated at .73, and the composite score correlated at .91 with the

Table 3. Pearson Bivariate correlations between IU (trait and situation-specic) and symptom measures Symptom measure SIPS BSQ/ACQ composite PSWQ PIsqrt BDI-II IUS-SS .27** .50** .41** .29** .38** IUS-12 .47** .39** .50** .30** .43** P-IU .42** .36** .50** .31** .37** I-IU .46** .36** .42** .25* .45**

Note. IUS-SS, Intolerance of Uncertainty Scale Situation-Specic version; IUS-12, Intolerance of Uncertainty Scale-12; P-IU, Prospective Intolerance of Uncertainty; I-IU, Inhibitory Intolerance of Uncertainty; SIPS, Social Interaction Phobia Scale; BSQ, Body Sensations Questionnaire; ACQ, Agoraphobic Cognitions Questionnaire; PSWQ, Penn State Worry Questionnaire; PI, Padua Inventory; BDI-II, Beck Depression Inventory.

*p , .05. **p , .01.

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BSQ and .95 with the ACQ, suggesting that the composite score reected scores on both measures. All correlations were positive and statistically signicant ( ps , .05), which suggests that both trait and situation-specic IU were associated with symptoms of internalising disorders.

Regression analyses examining unique contributions of IU to symptoms

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We employed a series of hierarchical multiple linear regression analyses to explore if IU explained unique variance in symptom

measures. For each regression, P-IU and I-IU were entered in step 1, while the IUS-SS was entered at step 2. Five separate models were run for the following criterion variables: SIPS, PSWQ, BSQ/ACQ composite, PIsqrt, and BDI-II. As seen in Table 4, the IUS-12 subscales explained a signicant proportion of variance in all symptoms measures. I-IU signicantly predicted social anxiety and depression symptoms at step 1, while P-IU predicted symptoms of GAD, panic disorder, and agoraphobia. Part rs indicated that P-IU was also a stronger predictor of OCD

Table 4. Summary of hierarchical linear regressions for trait IU subscales and situation-specic IU predicting symptom scores Criterion SIPS Predictors Step 1: P-IU I-IU Step 2: P-IU I-IU IUS-SS Step 1: P-IU I-IU Step 2: P-IU I-IU IUS-SS Step 1: P-IU I-IU Step 2: P-IU I-IU IUS-SS Step 1: P-IU I-IU Step 2: P-IU I-IU IUS-SS Step 1: P-IU I-IU Step 2: P-IU I-IU IUS-SS

DR 2
.17*** .002

B .28 .90 .23 .85 .07 .61 .30 .54 .23 .10 .64 .47 .26 .18 .47 .08 .02 .06 .001 .03 .16 1.05 2 .06 .84 .30

SEB .28 .37 .30 .38 .14 .20 .27 .21 .28 .10 .28 .37 .29 .36 .13 .04 .06 .04 .06 .02 .21 .30 .22 .30 .11

Beta .13 .31 .10 .29 .06 .38 .13 .33 .11 .10 .29 .17 .12 .06 .39 .26 .06 .20 .003 .17 .09 .41 2 .03 .33 .28

t 1.01 2.42* .76 2.22* .51 3.07** 1.09 2.57* .83 .96 2.27* 1.29 .92 .51 3.61*** 1.92 .41 1.40 .02 1.49 .73 3.54** 2 .26 2.79** 2.95**

Part r .09 .21 .07 .19 .04 .25 .09 .21 .07 .08 .19 .11 .07 .04 .29 .18 .04 .13 .00 .14 .05 .25 2 .02 .19 .20

PSWQ

.23*** .01

BSQ/ACQ composite

.18*** .08***

PIsqrt

.09* .02

BDI-II

.24*** .04**

Note. IUS-SS, Intolerance of Uncertainty Scale Situation-Specic version; P-IU, Prospective Intolerance of Uncertainty; I-IU, Inhibitory Intolerance of Uncertainty; SIPS, Social Interaction Phobia Scale; PSWQ, Penn State Worry Questionnaire; BSQ, Body Sensations Questionnaire; ACQ, Agoraphobic Cognitions Questionnaire; PI, Padua Inventory; BDI-II, Beck Depression Inventory.

*p , .05. **p , .01. ***p , .001.

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symptoms than I-IU was, although neither was a signicant independent predictor. At step 2, trait IU scales continued to explain variance in symptoms of social phobia and GAD, whereas situation-specic IU failed to explain an additional portion of variance in these symptoms. Conversely, situationspecic IU explained unique variance in symptoms of depression, panic disorder, and agoraphobia over and above trait IU scales. VIFs for each regression did not indicate problematic collinearity (OBrien, 2007; SIPS: 1.77 2.56; PSWQ: 1.69 2.45; BSQ/ACQ composite: 1.79 2.67; PIsqrt: 1.65 2.48; BDI-II: 1.92 3.05).

Discussion
IU has been most heavily implicated in the development and maintenance of excessive worry and GAD; however, recent research suggests that IU contributes to a range of symptoms across the emotional disorders (Gentes & Ruscio, 2011; McEvoy & Mahoney, 2011). Existing research has examined trait or trans-situational IU. This study is the rst to investigate IU associated with diagnosisspecic situations that are particularly distressing for individuals with anxiety and depressive disorders. This study sought to compare trait and situation-specic IU by developing a measure of situation-specic IU (the IUS-SS) and subsequently examining its factor structure, internal reliability, norms, differences across gender, and relationships with measures of personality dimensions and symptoms associated with anxiety and depressive disorders. Recent research suggests that trait IU is not a unitary construct; in student and treatmentseeking samples, it has been shown to consist of two factors, namely, P-IU and I-IU (Carleton et al., 2007; McEvoy & Mahoney, 2011). Our rst hypothesis was that situationspecic IU would also comprise of these two components; however, this hypothesis was not supported. The IUS-SS had a unitary factor structure that suggests that IU in relation to diagnostically pertinent situations is more homogeneous than trait IU. When considering particularly distressing situations, the anticipation and avoidance of associated aversive uncertainty (i.e., prospective and inhibitory components, respectively) appear to be highly

related experiences for people with anxiety and depressive disorders. Further psychometric evaluation of the IUS-SS suggested that the measure demonstrated excellent internal reliability and good convergent validity as indicated by positive relationships with neuroticism and trait IU. As predicted, this study also found evidence to support the discriminant validity of the IUS-SS as shown via non-signicant associations with measures of extraversion and alcohol use. We also found additional evidence for the divergent validity of the IUS-12 via its non-signicant association with alcohol use. We predicted that participants would report more situation-specic IU than trait IU. This prediction was supported; mean IUS-SS scores were signicantly higher than those on the IUS-12. This suggests that people with anxiety disorders nd uncertainty more aversive when it is encountered in situations that are particularly difcult for them (e.g., social interactions for individuals with social phobia). Previous studies have demonstrated associations between trait IU and symptoms of internalising disorders (e.g., de Jong-Meyer et al., 2009; McEvoy & Mahoney, 2011; Steketee et al., 1998), and this study extends existing research by nding signicant, positive correlations between situation-specic IU and an array of symptoms including those associated with GAD, social anxiety, depression, OCD, panic disorder, and agoraphobia. These results support the transdiagnostic nature of IU and enrich our understanding of the relationships between IU and symptoms of emotional disorders. Our last hypothesis was that situationspecic IU would explain unique variance in symptoms of anxiety and depressive disorders. P-IU was a unique predictor of excessive worry, which concurs with previous research (Buhr & Dugas, 2006; Laugesen, Dugas, & Bukowski, 2003; McEvoy & Mahoney, 2011). This nding suggests that individuals with excessive worry fear future uncertainty, which is consistent with the fact that worry is generally future-oriented or anticipatory in nature (Papageorgiou & Wells, 1999; Watkins, Moulds, & Mackintosh, 2005). Situation-specic IU was not a unique predictor of worry after taking trait IU into account. This nding may be inuenced by measurement factors in that both the PSWQ and the IUS-12 assess trait-like constructs.

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Nevertheless, these results are consistent with theoretical conceptualisations of worry and current cognitive models of GAD, which highlight the importance and relevance of trait IU (Dugas et al., 1998; Sexton et al., 2003; van de Heiden et al., 2010). Trait IU also predicted symptoms of social phobia, specically I-IU. This replicates previous ndings (Boelen & Reijntes, 2009; Carleton et al., 2010; McEvoy & Mahoney, 2011) and indicates that inaction or avoidance in response to uncertainty may be most predictive of social anxiety symptoms. IIU was also a signicant predictor of depression symptoms and may suggest that depression is more strongly related to restriction and constraint in response to uncertainty. This concurs with McEvoy and Mahoneys (2011) study and may reect the fact that depression is generally associated with withdrawal and inactivity, the function of which may be to imbue the individual with a sense of control and certainty, albeit pessimistic and thus depressogenic (Dupuy & Ladouceur, 2008; Yook, Kim, Suh, & Lee, 2010). Situation-specic IU was a signicant predictor of symptoms associated with depression, panic disorder, and agoraphobia after trait IU was taken into account. That is, IU specically associated with diagnostically pertinent situations contributed to the prediction of symptoms of panic disorder and depression over and above trait levels of IU. Again, not only do these ndings support the transdiagnostic conceptualisation of IU but also suggest that disorders may differ in the degree to which IU is generalised or specic to diagnosis-related situations. Similar to previous studies, trait and situation-specic IU correlated signicantly with OCD symptoms, and together the IUS12 subscales explained a signicant albeit relatively small proportion of variance in PI scores (Holaway, Heimberg, & Coles, 2006; Lind & Boschen, 2009; McEvoy & Mahoney, 2011; Steketee et al., 1998). P-IU was more strongly associated with OCD symptoms than I-IU, which is consistent with previous ndings (McEvoy & Mahoney, 2011), although neither remained a signicant unique predictor in the model. Given that IU has been found to be robustly associated with OCD symptoms in previous studies (Gentes & Ruscio, 2011), methodological differences may have inuenced our results. Previous studies used considerably larger sample sizes

(particularly for those with clinically signicant OCD symptoms) and thus had greater opportunity to detect associations than the current study did. The OCD literature has also generally used different measures of IU, and the IUS has been found to be more strongly associated with symptoms of GAD than OCD (Gentes & Ruscio, 2011). Our ndings have several theoretical and clinical implications. For instance, the fact that trait IU predicted worry supports the Intolerance of Uncertainty Model of GAD aume, Freeston, & (Dugas, Letarte, Rhe Ladouceur, 1995; Dugas et al., 1998) as well as GAD treatments that target trait IU (see Dugas et al., 2010). Replicating McEvoy and Mahoneys (2011) ndings, this study found that the P-IU was a more robust predictor of worry than I-IU. This aspect of IU could be addressed in GAD treatment by challenging relevant unhelpful cognitions and behaviours, such as restructuring the belief one should always look ahead so as to avoid surprises and reducing associated safety behaviours including excessive contingency planning. Behavioural experiments could be conducted to test the true consequences of presentfocused attention in the face of uncertainty, rather than pursuing the unachievable goal of anticipating and controlling uncertain situations. Although excessive worry is the hallmark of GAD, elevated worry is a common feature of many internalising disorders (American Psychiatric Association, 1994), and thus trait IU may still need to be considered when formulating difculties for individuals with other anxiety disorders and depression. Trait IU, and I-IU in particular, also predicted social phobia symptoms. Here, cognitive interventions may address beliefs such as when its time to act uncertainty paralyses me, whereas behavioural strategies could reduce avoidance via graded exposure to uncertain situations (e.g., impromptu speeches or spontaneous social interactions). On the other hand, situation-specic IU predicted symptoms of depression, panic disorder, and agoraphobia. Thus, to address these symptoms it may be helpful in treatment to assess and modify IU in relation to specic distressing situations that are diagnostically pertinent. Existing treatment protocols often seek to modify distorted thinking and maladaptive behaviours in relation to specic

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situations of core concern (e.g., exposure to crowded places in cognitive behavioural group therapy for panic disorder and agoraphobia; Andrews et al., 2003). Addressing IU-related fears and avoidance behaviours may be a useful adjunct to these interventions. The contribution of IU to internalising disorders should not be overstated. Although various aspects of IU predicted symptoms of anxiety disorders and depression, the proportion of variance explained was modest. Moreover, additional constructs thought to maintain anxiety and depressive symptoms were not taken into account (e.g., repetitive negative thinking, anxiety sensitivity, or metacognitive beliefs), and so interactions between potential maintaining factors could not be explored. For example, Yook et al. (2010) found that rumination fully mediated the relationship between IU and depression symptoms and Sexton et al. (2003) found that IU was not directly associated with symptoms of panic disorder in a model that included both IU and anxiety sensitivity. Thus, the mechanisms through which IU inuences symptoms require further clarication. In the clinic, it is therefore likely that the relevance of IU may vary across patients, and additional maintaining factors such as behavioural avoidance will continue to contribute heavily to clinical conceptualisations. Future research is needed to examine the comparative importance of IU within existing diagnosis-specic and transdiagnostic cognitive models of anxiety and depressive disorders as well as demonstrate whether IU-based interventions increase the effectiveness of current CBT treatments. There are additional limitations to this study. The cross-sectional nature of this study precludes casual conclusions, and further work with experimental paradigms is needed. For example, although existing research has shown that experimentally increasing IU leads to increased worry (e.g., Grenier & Ladouceur, 2004), future studies may explore whether increasing trait or situation-specic IU exacerbates symptoms of other internalising disorders. Also, the number of participants in the current study with a primary depressive disorder was small. Future research is needed to investigate IU in relation to primary depression and depressogenic situations. This study found good evidence for the reliability and validity for a situation-specic

measure of IU. The scale demonstrated a unitary factor structure, excellent internal consistency, and good convergent and divergent validity. Situation-specic IU was found to be associated with a broad array of anxiety and depression symptoms supporting the transdiagnostic nature of this construct. Moreover, situation-specic IU predicted symptoms of depression, panic disorder, and agoraphobia over and above trait IU.

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