Intolerance of uncertainty(IU) refers to difficulty tolerating uncertain situations and reacting negatively to ambiguity. It involves negative beliefs about uncertainty and strong emotional, cognitive, and behavioral responses to uncertain situations.
This might include worrying about a future event, thinking of all the worst-case scenarios, replaying a past scenario, predicting how something will play out, or planning something to every last detail.
Rituals, avoidance behaviors, and safety behaviors in OCD can be understood as ways for individuals to seek certainty when faced with uncertainty.
Intolerance of uncertainty is evident across OCD symptom dimensions. For contamination OCD, uncertain situations include potential contact with germs. In harm OCD, uncertainty involves perceived threats to self/others. With unacceptable thoughts, uncertainty stems from implications about morality.Checking OCDinvolves uncertainty about mistakes.Ordering/symmetry OCDstems from uncertainty about imperfection. Overall, compulsions function to reduce distress from uncertainty.
Key Points
Rationale
Cognitive models highlight maladaptive beliefs as risk factors, including intolerance of uncertainty, or difficulty tolerating uncertain situations (Steketee et al., 1998; Tolin et al., 2003).
Intolerance of uncertainty has been frequently studied in relation to worry andgeneralized anxiety disorder(Dugas et al., 2004).
However, its role as a cognitive vulnerability specifically implicated in the development and maintenance of OCD requires additional empirical examination (Gentes & Ruscio, 2011).
Establishing intolerance of uncertainty as a causal risk factor for OCD can facilitate translational research and inform treatment development (Einstein, 2014).
Method
This paper reviewed the literature on intolerance of uncertainty and OCD using PsycInfo and Google Scholar. It evaluated evidence based on criteria for establishing a cognitive vulnerability (Koerner & Dugas, 2008):
Sample
The literature reviewed included clinical and nonclinical samples with a range of OCD severities and symptom profiles.
Studies frequently compared OCD samples to non-anxious controls. Some studies also included samples with other anxiety disorders.
Statistical Analysis
Associations between intolerance of uncertainty and OCD symptoms were typically examined through correlation and regression analyses.
Manipulation studies usedANOVAto test group differences in OCD symptoms after the uncertainty induction. Within-subject effect sizes were also reported.
Results
Association with OCD symptoms
Stability over time
Role as a causal risk factor
Malleability to intervention
Insight
This review highlights the need for additional rigorous tests of intolerance of uncertainty as a causal risk factor for OCD using longitudinal and experimental designs.
Understanding developmental pathways and multimodal correlates can further elucidate the role of intolerance of uncertainty in OCD.
If increasing tolerance of uncertainty proves to be a mechanism of effective OCD treatment, directly targeting intolerance of uncertainty in therapies may improve outcomes for this difficult-to-treat disorder.
Strengths
Limitations
Implications
This review suggests intolerance of uncertainty likely contributes to OCD but may not fully explain its onset and maintenance across the lifespan.
Both cognitive and behavioral approaches to target intolerance of uncertainty warrant additional study as a potential focus within CBT for OCD.
Changes in intolerance of uncertainty over the course of development, especially from early childhood to disorder onset, require examination.
Clinical Practice
Conclusion
Overall, intolerance of uncertainty meets many but not all criteria for a cognitive vulnerability for OCD based on the literature to date.
There is a clear association with OCD symptoms and evidence of relative stability. However, more rigorous tests of the causal role of intolerance of uncertainty in OCD and isolation as a mechanism of effective treatment are needed.
Developing and testing interventions that specifically target intolerance of uncertainty in OCD patients would significantly advance this literature.
Understanding the complex role intolerance of uncertainty plays in this debilitating disorder may inform translational research on both etiology and treatment.
References
Further Reading
Einstein, D. A. (2014). Extension of the transdiagnostic model to focus on intolerance of uncertainty: a review of the literature and implications for treatment.Clinical Psychology: Science and Practice,21(3), 280.
Learning Check
What evidence suggests intolerance of uncertainty is a cognitive vulnerability specific to OCD compared to a general risk factor for emotional disorders? Does the current research sufficiently establish specificity?What are the ethical implications of experimentally manipulating intolerance of uncertainty? Could attempts to temporarily increase intolerance of uncertainty be harmful for some participants?Would directly targeting intolerance of uncertainty in CBT for OCD improve treatment outcomes? What are some techniques that could be used? What are potential limitations of focusing on intolerance of uncertainty?How might intolerance of uncertainty develop over the course of childhood? What longitudinal research is needed to understand the trajectory of intolerance of uncertainty prior to onset of OCD?Could intolerance of uncertainty be adaptive in some situations? If so, how might we determine the line between adaptive and maladaptive intolerance of uncertainty?
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
