Intolerance of uncertainty in obsessive-compulsive disorder
Introduction
Individuals with obsessive-compulsive disorder (OCD) often exhibit pathological doubt about the properties of a stimulus, situation, or action (e.g., Rasmussen & Eisen, 1989; Reed, 1985). This phenomenon is seen across the range of OCD subtypes: for example, patients often report serious doubt about whether they have washed their hands sufficiently, have committed sins, or have discarded an important item. However, pathological doubt is most clearly evident among patients with checking rituals (Rachman & Hodgson, 1980; Rasmussen & Eisen, 1992). For example, a patient may experience persistent doubt about whether he turned off the stove completely; in response to this worry, he may check the stove repeatedly to make sure it is off. Another patient may doubt whether she accidentally hit a pedestrian with her car; she may cope with this distress by circling the block to make sure no one has been harmed.
Neuropsychiatric models of OCD posit that such behaviors might reflect impairments in verbal and/or nonverbal memory (Deckersbach, Otto, Savage, Baer, & Jenike, 2000); however, empirical evidence for such deficits has been mixed (Abbruzzese, Bellodi, Ferri, & Scarone, 1993). Other research has linked pathological doubt with decreased confidence in one’s own memory, rather than global or specific memory deficits (e.g., Foa, Amir, Gershuny, Molnar, & Kozak, 1997; MacDonald, Antony, MacLeod, & Richter, 1997; McNally & Kohlbeck, 1993). Recently, Tolin et al. (2001) found that individuals with OCD (OCs) who had primarily checking compulsions had lower memory confidence for objects perceived as unsafe, compared to nonanxious control participants (NACs) and OCs with other types of compulsions (e.g., washing). Thus, the available data suggest a link between low memory confidence and OCD, particularly among those with checking behaviors. Nevertheless, compulsive checking is not generally observed in individuals with major depression, traumatic brain injury, or the normal aging process, all of which might also be characterized by poor memory confidence. What, then, might account for urges to perform compulsive rituals in OCD, but not in these other conditions?
One possible explanation is that OCs find uncertainty itself to be highly distressing and engage in compulsive rituals to restore certainty (e.g., Carr, 1974; Guidano & Liotti, 1983). Constans, Foa, Franklin, and Mathews (1995) found that despite no differences in reported memory vividness, OCs stated that they desired more vivid memories than did NACs. This exaggerated discrepancy between actual and desired quality of memory suggests an intolerance of uncertainty (IU), a construct that has been postulated to play a central role in anxiety (Krohne, 1989). Freeston, Rhéaume, Letarte, Dugas, and Ladoceur (1994) developed a self-report questionnaire to measure the construct of IU, which they described as “behavioral attempts to control the future and avoid uncertainty, inhibition of action based on uncertainty, emotional reactions such as frustration and stress, and cognitive interpretations that being uncertain reflects badly on a person” (p. 799). Student volunteers with self-reported symptoms of generalized anxiety and worry were shown to score higher on the IU scale than did those without such symptoms. In a later study, this same discrepancy was shown to exist independently of depression and trait anxiety (Dugas, Freeston, & Ladoceur, 1997). IU has been associated with increased information-seeking in a moderately ambiguous problem-solving task (Ladoceur, Talbot, & Dugas, 1997). In a recent experimental study, elicitation of greater IU led to increases in reported worry compared to lower IU (Ladoceur, Gosselin, & Dugas, 2000). Thus, there is converging evidence for a specific relationship between IU and worry.
Early research also suggests that IU is present among individuals with OCD. When asked to label ambiguous line drawings, “obsessional neurotics” were less likely than other patient groups to give “can’t decide” responses, suggesting avoidance of ambiguity (Hamilton, 1957). Another plausible explanation, however, is that the obsessional participants were less willing to report uncertainty. Obsessive patients also asked for more repetitions of a target sound embedded in white noise when asked to make judgments about the sound (Milner, Beech, & Walker, 1971). It is unclear, however, whether this was due to IU or to decreased confidence in one’s perception (e.g., Tolin et al., 2001). Some preliminary evidence for IU among OCD patients comes from a survey of members of national groups of anxiety-disordered individuals (Steketee, Frost, & Cohen, 1998). Individuals with OCD reported less ability to tolerate uncertainty than did nonanxious and anxious control groups. However, this study did not include any independent verification of diagnostic status or severity. Rather, participants were grouped according to self-reported diagnosis of OCD or other anxiety disorders, and the OC group included individuals with Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores that were below the clinical range. Furthermore, participants in this study were members of national support and information organizations, raising the possibility of sampling bias. Thus, although the preliminary results are encouraging, additional controlled research is needed to increase confidence in the results and facilitate their interpretation.
The purposes of the present study are: (1) to explore the psychometric properties of the Intolerance of Uncertainty Scale (IUS) in a clinical sample, and (2) to examine the relationship between IU and OCD in a clinical sample. We predicted that OCD patients would exhibit greater IU compared to a sample of nonanxious controls. We further hypothesized that IU would be particularly pronounced among OCD patients with checking compulsions.
Section snippets
Participants
Fifty-five individuals with OCD (OCs) and fourteen NACs participated in this study. The OCs were recruited from consecutive admissions to an outpatient anxiety clinic and met DSM-IV (American Psychiatric Association, 1994) criteria as determined by the Structured Clinical Interview for DSM-IV (SCID). OCs were excluded if they: (1) met criteria for a current primary DSM-IV Axis I disorder other than OCD, (2) had a history of organic brain disorder, schizophrenia, or bipolar disorder, or (3) had
Results
Demographic and questionnaire variables are shown in Table 1. As can be seen in the Table 1, the three participant groups did not differ in terms of age or gender. OC checkers reported significantly higher levels of depression than did NACs. Importantly, OC checkers and OC noncheckers did not differ in terms of overall OCD symptom severity. However, small sample size and low statistical power (observed power=.43) limit interpretability of this finding.
In the present sample, the IUS showed
Discussion
The construct of IU holds promise for cognitive-behavioral models of anxiety disorders such as OCD. However, to date the IUS has not been studied extensively in clinical populations. In the present sample of OCD patients, the IUS showed good psychometric properties; thus, the scale seems to be appropriate for use in treatment-seeking samples of OCs.
The present results were partially supportive of our hypotheses. In particular, our data were consistent with our prediction that OC checkers would
Acknowledgements
The authors thank Roxanne Jensen and Demetrius Synodi for their invaluable assistance.
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