Working with intolerance of uncertainty
Helen Holmes
Director, Senior Consultant Psychologist, Psychotherapist, Counsellor & Supervisor in private practice - Author, Poet, Philosopher, Lecturer and Social Activist. Dedicated to improving severe mental health difficulties.
This article reports on therapy for Generalized Anxiety Disorder (GAD) mainly following the Intolerance of Uncertainty model (IoU, Dugas, 2004). The literature review defines GAD with relevance to 'Sam' (pseudonym), then outlining the salient evidence regarding treatment of IoU. A case report on Sam then follows.
Literature review
Definition of GAD
DSM IV (American Psychiatric Association, [APA], 1994), defines GAD depending on assessing symptom frequency, severity, and timescale regarding the current presentation and disorder development (National Institute for Health and Care Excellence [NICE], 2011). Sam presented core GAD symptoms: excessive anxiety and worry over varying situations; problems managing worrying daily for 6-months minimum, alongside: restlessness, being easily fatigued, concentration difficulties, irritability, muscle tension and sleeplessness.
Theory and techniques of treating IoU
According to Dugas (2004), IoU evokes worry via ‘’What if..?’’ questions, involving event triggered: worry, anxiety, demoralization and fatigue. Therefore, increasing Sam’s tolerance of uncertainty, was paramount. IoU treatment improves co-morbidity symptoms. A study by Maes, Davenport, and Kiropoulos (2023), proposed transdiagnostic cognitive strategies targeting IoU and emotion regulation, lessening the effects of adverse childhood experiences regarding comorbid anxiety, depression and eating disorder (ED) symptoms. Additionally, Williams & Levinson (2021) investigated EDs, perfectionism and obsessive-compulsive disorder (OCD) finding targeting unhelpful perfectionism and IoU, amongst individuals with EDs, may prevent OCD developing.
Regarding IoU, Sandhu, Xiao, and Lawson (2023), investigated misestimations of uncertainty in a narrative review, finding computational construction reframing IoU as individual differences in clarifying uncertainty (Pulcu & Browning, 2019). They recommended future research regarding the synergy between uncertainty and the function of cognitive processes, clarifying misestimating uncertainty across disorders.
Later IoU treatment targeted behavioral experiments (BEs) (Hebert & Dugas, 2019), as a Randomized Control Trial (RCT) for adults attests (Dugas et al., 2022). Sixty participants (51 women; 9 men; mean age = 34.60), were randomized to waitlist, control or treatment groups. Participants underwent 12, one-hour weekly sessions, involving BEs, trialing catastrophizing beliefs regarding uncertainty. Growth curve modelling was applied, discovering that: 1. The treatment cohort rated higher regarding alteration from pre- to post-test, over all results; 2. The amalgamated population demonstrated significant declines of all results and 3. The treatment benefits were maintained or increased over the 12-month study follow-up (Dugas et al., 2022).
Dugas worked closely with Robichaud, publishing CBT developments for GAD (Robichaud, 2023) targeting excessive worry through fear of uncertainty, via BEs and decision-making difficulties. Positive beliefs were challenged about worrying being helpful, alongside targeting residual worries by problem-solving and exposure, with relapse prevention and maintaining benefits. As Robichaud (2023) proposed, CBT-IoU should include: psychoeducation regarding GAD, awareness about worrying and safety behaviours, identifying and challenging negative beliefs regarding uncertainty, BEs, reevaluating positive beliefs about worry, problem orientation, skills training, and processing of main fears via written exposure and relapse prevention. As Robichaud (2023) notes, targeting IoU through examining negative beliefs about uncertainty, underpinning GAD, is key.
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Outcomes for CBT for IoU
According to Freeston’s (2023) metanalysis, GAD has a high co-morbidity lifetime and shared features, such as: worry, irritability, sleep, and fatigue (Dugas et al., 1998). IoU treatment indicates transdiagnostic strategies, specifying customary processes, alongside successfully treating different disorders, such as: panic, depression and EDs (Bottesi et al., 2020; McEvoy et al., 2019). A recent historical review, highlights IoU as an effective trans-therapeutic change process, across disorders (Crocq, 2022). For Freeston (2023), when IoU is well-matched with individuals, IoU’s specific targets achieve better outcomes than wider-ranging treatments, potentially reflecting similar group outcomes.
Furthermore, Zemestani et al’s (2021) clinical trial, compared CBT-IoU efficacy with selective serotonin reuptake inhibitors (SSRI) in GAD treatment. Thirty Iranian participants were equally randomized. Repeated measures analysis was applied to variance tested differential treatment outcomes. CBT-IoU was found to create superior results to SSRI post-treatment. This RCT supports cross-cultural GAD treatment using IoU, demonstrating this non-pharmacological model reducing GAD symptoms.
According to Laposa et al’s (2019) pilot study, there are longitudinal changes in IoU and worry severity during CBT-IoU for GAD. IoU is considered either as unidimensional or bi-dimensional (inhibitory and prospective). Ninety GAD participants returned regular IoU and worry measures: pre-treatment to session 12, during group CBT for GAD. Longitudinal multilevel modelling demonstrated that IoU predicated worry ratings jointly, but not prospectively over time; collated from IUS ratings. The association between inhibitory but not prospective IoU and worry, increased over time. Change in IoU, is linked with modification in worry during CBT.
Adaptations
According to Robichaud (2013), there were few GAD-IoU adaptations to ethnicity and gender but some to children, adolescents and older-adults. A study by Yuniardi et al. (2021) explored interactions between IoU and anxiety or depression, during the pandemic among 406 Indonesians. The findings indicated, IoU constituting a risk component for enhanced emotional and behavioural problems, possibly leading to anxiety or depression through COVID-19.
Additionally, Chigwedere and Moran (2022), developed the IoU model naturalistically, investigating reasons for 7 cases responding negatively to uncertainty, from developmental and attachment perspectives. Worry results improved from pre- to post-treatment. More studies are needed. This approach demonstrates potential as a standalone or complementary treatment.
Sam’s dyslexia diagnosis, required digital recovery application adjustments during therapy. Gu et al. (2020) found obstacles to accessing CBT, are bypassed through especially smartphone-delivered CBT. This protocol stipulates digital therapy for anxiety, necessitating a parallel-group superiority RCT, examining the outcome of a novel smartphone-delivered CBT therapy for GAD, compared with a wait-list control. Two hundred-and-forty-two adults participated, with moderate-to-severe GAD difficulties, with baseline assessments and at weeks 3, 6 and 10. The findings potentially contribute to evaluating digital CBT for GAD.
Conclusion
GAD diagnosis includes: excessive anxiety and worry over varying events, and problems managing worrying. IoU leads to worry via ‘’What if…?’’ questions involving worry, anxiety, demoralization and fatigue. Increasing capacity to tolerate uncertainty is key to Dugas (2004). BEs are important for treating IoU. Recent studies demonstrate IoU as effectively treating comorbidities including GAD, for individuals and groups. IoU has been adapted to some cultural contexts, age, attachment styles and digitally. However, more gender and other demographic adapted GAD-IoU research is needed.