2009 - intolerance of uncertainty and social anxiety. - boelen, reijntjes.pdf

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Intolerance of uncertainty and social anxiety

Paul A. Boelen a,*, Albert Reijntjes b

a Department of Clinical and Health Psychology, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, The Netherlandsb Department of Psychosocial Development in Context, Utrecht University, The Netherlands

1. Introduction

Anxiety disorders are among the most prevalent of all

psychiatric disorders (Kessler, Berglund, Demler, Jin, & Walters,

2005). The recent decades have seen advancement of our

understanding of the etiology of anxiety disorders. An important

premise in theories about anxiety disorders is that they contain

both common and unique components (Brown & Barlow, 2002;

Mineka, Watson, & Clark, 1998). Specifically, theorists have

proposed and research has confirmed that all anxiety disorders

(as well as mood disorders) involve elevated levels of negative

affectivity or neuroticism (Mineka et al., 1998), whereas specific

cognitive factors are responsible for the development of specific

anxiety disorders. Examples of such specific factors include anxiety

sensitivity in panic disorder, fear of negative evaluation in social

phobia, excessive responsibility beliefs in obsessive compulsive

disorder (OCD), and intolerance of uncertainty in generalized

anxiety disorder (GAD) (cf.Starcevic & Berle, 2006).

Identifying factors that are unique to specific anxiety disorders

is importantfor understanding andtreatment of these disorders. In

recent years, there is growing interest in one of such specific

factors, namelyintolerance of uncertainty (IU). IU has been defined

as a cognitive bias that affects how a person perceives, interprets,

andrespondsto uncertainsituations on a cognitive, emotional, andbehavioral level (Dugas, Schwarzt, & Francis, 2004, p. 835). People

high in IU experience the possible occurrence of future negative

events as stressful, believe that uncertainty is negative, reflects

badly on a person, and should be avoided, and have difficulties

functioning well in uncertain situations (Buhr & Dugas, 2002).

In studies with non-clinical samples (e.g.,Holaway, Heimberg,

& Coles, 2006) and clinical samples (e.g., Dugas & Ladouceur, 2000)

IU has consistently been found to be correlated with GAD.

Nevertheless, studies examining specificity of IU to GAD have

yielded mixed results (Starcevic & Berle, 2006). On the one hand,

there is evidence that IU is a relatively unique component of GAD.

For instance, studies have shown that high levels of IU distinguish

patients with GAD from patients with panic disorder (Dugas,

Marchand, & Ladouceur, 2005) and from a mixed group of patients

with other anxiety disorders (Ladouceur et al., 1999). Moreover, IU

has been found to be more strongly related with pathological

worry which is a key symptom of GAD than with depression

(Dugas et al., 2004). On theotherhand,thereare studies suggesting

that IU is critical to both GAD and OCD. For instance, in a study

among undergraduate students,Holaway et al. (2006)found that

people with clinical significant levels of GAD and OCD reported

higher levels of IU than controls, but did not differ significantly

from each other in terms of IU levels (also seeSteketee, Frost, &

Cohen, 1998;Tolin, Abramowitz, Brigidi, & Foa, 2003).

To our knowledge, no studies have yet examined the relation-

ship of IU with social anxiety. Yet, it is possible that IU contributes

Journal of Anxiety Disorders 23 (2009) 130135

A R T I C L E I N F O

Article history:

Received 6 March 2008Received in revised form 29 April 2008

Accepted 29 April 2008

Keywords:

Social-anxiety

Intolerance-of-uncertainty

A B S T R A C T

Research has shown that intolerance of uncertainty (IU) the tendency to react negatively to situations

that are uncertain is involved in generalized anxiety disorder (GAD). There is uncertainty about thespecificityof IU.Some studies have shown thatIU is specific for GAD. Otherstudies have shownthat IU is

also involved in obsessive compulsive disorder (OCD). No studies have yet examined IU in social anxiety,

although it is possible that IU plays a role in anxiety responses that can be experienced in social-

evaluative situations. This study examined the relationship between IU and social anxiety among 126

adults. Findings revealed that IU explained a significant amount of variance in social anxiety severity

when controlling for established cognitive correlates of social anxiety (e.g., fear of negative evaluation)

andfor neuroticism. Furthermore,it wasfound that IU wasrelatedwith symptom levelsof GAD, OCD, and

social anxiety, but not depression, when controlling the shared variance among these symptoms.

2008 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +31 30 2533021; fax: +31 30 2534718.

E-mail address: [email protected](P.A. Boelen).

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

0887-6185/$ see front matter 2008 Elsevier Ltd. All rights reserved.

doi:10.1016/j.janxdis.2008.04.007
mailto:[email protected]://www.sciencedirect.com/science/journal/08876185http://dx.doi.org/10.1016/j.janxdis.2008.04.007http://dx.doi.org/10.1016/j.janxdis.2008.04.007http://www.sciencedirect.com/science/journal/08876185mailto:[email protected]


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to the severity of social anxiety symptoms. People with elevated

social anxiety experience a marked and persistent fear in social

situations in which they are exposed to possible scrutiny by others

(Hofmann & Barlow, 2002). Clearly, uncertainty, ambiguity, and

unpredictable change are inherent to such social-evaluative

situations. Thus, it seems plausible that intolerance of such

uncertainty, ambiguity, and unpredictable change in the form

of finding that uncertainty is stressful, reflects badly on a person,and blocks constructive action (i.e., IU) is associated with thefear

(e.g., of being criticized), avoidance (e.g., of talking to strangers),

andphysical discomfort(e.g., blushing, trembling) that some people

experience in such situations.

The present study, conducted in The Netherlands, addressed

several interrelated issues, the overarching aim of which was to

improve our understanding of the role of IU in social anxiety.

Specifically, this study had two goals.

Thefirst goal wasto examine thedegree to which IU wasrelated

to social anxiety severity, when taking into account a number of

cognitive variables that have been found to be associated with

social anxiety. Cognitive behavioral models of social anxiety have

proposed (Clark & Wells, 1995; Rapee & Heimberg, 1997) and

research has confirmed (Weeks et al., 2005) that fear of negative

evaluation (FNE), defined as fear of being judged disparagingly,

critically, or hostilely by others, is strongly linked with social

anxiety. Furthermore, social anxiety has been found to be

associated withanxiety sensitivity (Orsillo, Lilienfeld, & Heimberg,

1994), low self-esteem (Kocovski & Endler, 2000), various dimen-

sions ofperfectionism (Juster et al., 1996), and with pathological

worry(Starcevic et al., 2007). Our first goal was to examine if IU

explainedvariance in social anxiety severity,aboveand beyondthe

variance explained by these established cognitive correlates of

social anxiety. Because we wished to examine the contribution of

IU and the other cognitive correlates to the explained variance in

social anxiety independent of neuroticism, this variable was

controlled for as well.

The second goal of this study was to further our understanding

of the generality vs. specificity of IU by examining the specificity ofthe relationship between IU and GAD, with regards to social

anxiety. For comparative reasons, we also included measures of

OCDand depression symptoms, expecting that IU would be related

with symptom levels of GAD, social anxiety, and OCD, but not

depression (Dugas et al., 2004), when controlling for the shared

variance between symptoms.

2. Method

2.1. Participants and procedure

Data were available from 126 adults. Participants were

originally recruited for a longitudinal study on coping with loss,

primarily designed to examine the predictive effects of varioustypes of coping behaviors on the development of complicated grief

(Boelen and Van den Hout, 2008). All participants were recruited

through an advertisement on an Internet-site that briefly

explained aims of the study on grief and invited people to

participate by filling in questionnaires. In total, 568 questionnaires

were sent to people who expressed their interest in participation

and 404 (71%) questionnaires were returned. Participants who had

suffered a loss less than 5 months prior to completion of the initial

questionnaires (N= 121) were invited to complete additional

questionnaires for the study on grief. All remaining participants

(N= 283) were invited to participate in the present study on IU.

This invitation and the questionnaires for the current study were

sent to them together with a brief written report on the outcomes

of the grief study for which they were originally recruited. Of these

283 participants, 126 (44.5%) completed the battery of ques

tionnaires for the current study. Participants did not receive any

financial compensation in return for their participation.

On average, participants were 47.7 (S.D. = 11.7) years of age

Most (91.3%) were woman. With respect to educational level, one

participant had finished primary school, 47.2% had finished high

school, and 52.0% had been to college or university. Losses that

participants had suffered all had occurred at least 18 months priorto participation in the present study.

2.2. Measures

The questionnaire package included a consent form, an

information letter, and the following measures. Questionnaire

were administered in the same order across participants.

2.2.1. Social Phobia Inventory (SPIN)

TheSPIN is a 17-item questionnaire constructed by Connoret al

(2000). It was designed as a concise measure for the assessment of

the fear, avoidance, and physiological symptoms that characterize

social phobia. Respondents rate the presence of symptoms in the

preceding week, on 4-point scales ranging from 0 (not at all) to 4

(extremely). Items are summed to form an overall social anxiety

severity score. The measure has been found to have good

psychometric properties (Connor et al., 2000). To construct the

Dutch version, the first and second author translated the English

version of the SPIN into Dutch. Then, an independent researcher

who was fluent in Dutch and English and familiar with the concept

of social anxiety checked if each question was properly translated

Discrepancies between both Dutch versions were then discussed

and cleared to make sure that the Dutch translation resembled the

original formulation as closely as possible. In the present sample

Cronbachsa of the SPIN was 0.93.

2.2.2. Intolerance of Uncertainty Scale (IUS)

The IUS is a 27-item measure of IU developed by Freeston

Rheaume, Letarte, Dugas, and Ladouceur (1994). It taps differentaspects of IU such as the idea that uncertainty is unacceptable

reflects badly on a person, and interferes with active coping

Respondents rate the degree to which each of 27 items apply to

them on 5-point scales ranging from 1 (not at all characteristic of

me)to 5 (entirely characteristic of me). The original French version

(Freeston et al., 1994) as well as the English version (Buhr & Dugas

2002), and the Dutch version used in this study (De Bruin, Rassin

van der Heiden, & Muris, 2006) have demonstrated adequate

psychometric properties. In the present sample, Cronbachs awas

0.95.

2.2.3. Brief Fear of Negative Evaluation Scale (BFNE)

The BFNE (Weeks et al., 2005) is a 12-item measure tapping the

fear to be judged negatively by others. Respondents rate the extento which items tapping this fear are characteristic of them on 5-

point scales ranging from 0 (not at all characteristic of me) to 4

(extremely characteristic of me). The scale has been found to have

adequate psychometric properties (Weeks et al., 2005). The Dutch

version was obtained from Bogels (2004) and, in the presen

sample, had an a of 0.97.

2.2.4. Anxiety Sensitivity Index (ASI)

The ASI is a 16-item questionnaire developed byPeterson and

Reiss (1992)designed to tap the tendency to fear anxiety-related

bodily sensations. Respondents rate the extent to which they

experienced fears represented in the items in the preceding week

on 5-point scales ranging from 0 (very little) to 4 (very much). Both

the English (Peterson & Reiss, 1992) and Dutch version (Vujanovic

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Arrindell, Bernstein, Norton, & Zvolensky, 2007) of the measure

have good psychometric properties. In this sample, the total score

was used as a global index of anxiety sensitivity and Cronbachs a

was 0.90.

2.2.5. Rosenberg Self-Esteem Scale (SES)

The SES is a 10-item measure of self-esteem developed by

Rosenberg (1989). Respondents rate their agreement with each of10 positively and negatively worded self-statements on 4-point

scales ranging from 0 (strongly agree) to 3 (strongly disagree). The

total score is calculated such that higher scores reflect lower self-

esteem. Both the English (Rosenberg, 1989) and Dutch version

(Franck, De Raedt, Barbez, & Rosseel, in press) have good

psychometric properties. Cronbachs a in the present sample

was 0.88.

2.2.6. Multidimensional Perfectionism Scale (MPS)

The MPS is a 35-item questionnaire of perfectionism developed

byFrost, Marten, Lahart, and Rosenblate (1990). It can be used to

obtain an overall index of perfectionism, as well as separate scores

for six dimensions of perfectionism: Concern over Mistakes (CM),

Doubts about Actions (DA), Personal Standards (PS), Parental

Expectations (PE), Parental Criticism (PC) and Organization (OR).

Respondents rate their level of agreement with each item on 5-

point scales ranging from 0 (strongly disagree) to 4 (strongly

agree). Psychometric properties of the measure are adequate (e.g.,

Frost et al., 1990) with the 6-factor structure being confirmed

(Juster et al., 1996). We only used three subscales that have been

found to be correlated with social anxiety: CM, DA, and PC (cf.

Juster et al., 1996; Rosser, Issakidis, & Peters, 2003). These

subscales were specifically translated for the current study, using

the procedure described with the SPIN. Cronbachs as of the

subscales in this sample were 0.92 for CM, 0.87 for DA, and 0.71

for PC.

2.2.7. Penn State Worry Questionnaire (PSWQ)

The PSWQ is a 16-item measure of pathological worrydeveloped by Meyer, Miller, Metzger, and Borkovec (1990).

Respondents rate degree to which items reflecting worry are

typical for them on 5-point scales ranging from 1 (not at all typical

of me) to 5 (very typical of me). Psychometric properties of the

original English version (Meyer et al., 1990) and Dutch version

(Rijsoort, van Emmelkamp, & Vervaeke, 1999) are adequate.

Cronbachsa in the present sample was 0.94.

2.2.8. Generalized Anxiety Disorder Questionnaire for

DSM-IV (GAD-Q-IV)

The GAD-Q-IV is a 9-item measure constructed by Newman

et al. (2002) toassess symptoms ofGAD as defined in DSM-IV(APA,

1994). It contains five dichotomous (yes/no) items tapping the

occurrence of worry,one item assessing worry topics, a checklist ofsix dichotomously scored somatic symptoms related to GAD, and

twoquestions assessing the degree of distress and disability linked

with the worry, scoredon 9-point scales ranging from 0 (none) to8

(very severe). TheGAD-Q-IV canbe used to eitherclassifycases and

non-cases of GAD or to obtain a continuous score of GAD severity.

In the current study, this latter scoring format was used. The

measure was specifically translated for the current study using the

procedure that was described with the SPIN. Cronbachs a in the

present sample was 0.89.

2.2.9. Depression Subscale of the Hospital Anxiety and Depression

Scale (HADS-D)

The 7-itemdepression subscale of theHADS (Zigmond & Snaith,

1983) was used to assess depressive symptom severity. Respon-

dents rate the presence of seven depressive symptoms on 4-point

scales, which are summed to yield a depression severity score. The

English (Zigmond & Snaith, 1983) and Dutch versions (Spinhoven

et al., 1997) have adequate psychometric properties. In the current

sample, Cronbachsa was 0.90.

2.2.10. Obsessive Compulsive Inventory revised version (OCI-R)

The OCI-R is an 18-item measure constructed by Foa et al.(2002) to assess OCD symptomatology. Respondents rate the

presence of OCD symptoms on 5-point scales ranging from not at

all to extremely. The OCI-R consists of six subscales (i.e.,

washing, checking, ordering, obsessing, hoarding, and neutraliz-

ing) and its total score provides a general index of OCD severity.

This total score was used in this study. Psychometric properties of

the English (Foa et al., 2002; Hajcak, Huppert, Simons, & Foa, 2004)

and Dutch version (Cordova-Middelbrink et al., 2007) of the OCI-R

have been found to be good. In this sample, Cronbachs a was 0.85.

2.2.11. Shortened Eysenck Personality Questionnaire (EPQ)

neuroticism subscale

The neuroticism subscale from the shortened EPQ (Eysenck,

Eysenck, & Barrett, 1985), the Dutch version of which was

developed and validated by Sanderman et al. (1995), was used

to asses the level of neuroticism. Respondents indicate their

agreement with items, using a forced-choice response format (yes

vs. no). In this sample, Cronbachsa was 0.87.

3. Results

3.1. Preliminary analyses

Table 1 shows means andS.D.s for all measures. Themean score

on the SPIN (tapping social anxiety) in the current sample was

M= 11.2 (S.D. = 11.2). This score was similar to the mean score of

M= 12.1 (S.D. = 9.3) of 68 healthy volunteers in thestudyofConnor

et al. (2000); (t(125) = 0.87,p = 0.39). IUS, PSWQ, and GAD-Q-IV

scores resembled those of student samples (cf. Dugas et al., 2004;Holaway et al., 2006). The same applied to scores on the BFNE (cf.

Weeks et al., 2005), OCI-R (Hajcak et al., 2004) and MPS subscales

(Juster et al., 1996). Mean HADS-D scores in this sample (M= 4.1,

S.D. = 4.3) did not differ significantly from the mean score of

M= 3.4 (S.D. = 3.3) of a non-clinical sample of 199 adults drawn

from the general Dutch population (t(125) = 1.80, p= 0.08)

(Spinhoven et al., 1997). Findings suggest that, although all

participants had experienced the death of a close relative, their

psychological distress was at the level of the normal population.

None of the scores on the study measures differed as a function

of gender or age of the participants. Normality data (e.g.,

skewnesses) indicated that all measures, except the GAD-Q-IV,

SES, and EPQ neuroticism subscale were positively skewed.

Therefore, these variables were log-transformed in all regressionanalyses presented below.

To be able to explore associations between the study measures,

nonparametric correlations (Spearman r) were calculated. These

are shown inTable 1. To examine the statistical significance of the

78 correlations that were calculated, a Bonferroni correction was

applied with the alpha level being set at 0.0006 (i.e., 0.05/78). All

correlations were significant, except the correlations between the

MPS subscale Parental Criticism and most other measures.

3.2. Regression with social anxiety severity as dependent variable

Next, we examined the extent to which IU explainedvariance in

social anxiety, when controlling for neuroticism and for the

following seven cognitive correlates of social anxiety: FNE, anxiety

P.A. Boelen, A. Reijntjes / Journal of Anxiety Disorders 23 (2009) 130135132


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sensitivity, low self-esteem, the three perfectionism subscales

from the MPS (i.e., CM, DA, and PC), and pathological worry. To this

end, we conducted hierarchical regression analysis predicting SPIN

scores, in which neuroticism was entered in block 1, the seven

cognitive variables were included in a stepwise analysis in block 2,

and IU was added to the equation in block 3. We used the stepwise

procedure in block 2 because we had a relatively large number of

correlated independent variables and a relatively small sample.

Findings are summarized inTable 2.

Outcomes showed that neuroticism (entered in block 1)

explained 38.1% of the variance in social anxiety. FNE and anxiety

sensitivity were consecutively selected into theequationin block 2

explaining an additional 14.7% and 2.3% of the variance,

respectively. IU, entered in block 3, accounted for an additional

4% of the variance in social anxiety severity. In the final model,

neuroticism, FNE, and IU emerged as unique correlates of social

anxiety. Anxiety sensitivity no longer had a unique associationwith social anxiety.

3.3. Relative importance of FNE and IU

Given that FNE and IU were the only two cognitive variables

that explained unique variance in social anxiety severity over and

above neuroticism, it was considered relevant to examine the

relative contribution of both variables to the explained variance in

SPIN scores when controlling for neuroticism. To this end, two

hierarchical regression analyses predicting SPIN scores were

carried out, one in which neuroticism and IU were entered in

the first block followed by FNE in block 2, and one in which

neuroticism and FNE were entered in the first block, followed by IU

in block 2.

The first of these regressions showedthat FNEexplained 6.6% o

the variance in social anxiety over and above the 51.6% explained

by neuroticism and IU (Fchange (1, 121) = 18.96, p < 0.001). The

secondregression showed that IU explained 5.4% of the variance in

SPIN scoresover andabovethe 52.8% explainedby neuroticism and

FNE (Fchange (1, 121) = 15.52, p < 0.001). Together, neuroticism

FNE, and IU explained 58.2% of the variance in social anxiety

severity (F(3, 124) = 56.14, p < 0.001).

3.4. Specificity of IU to social anxiety, GAD, OCD, and depression

In our final round of analyses, we examined the degree to which

IU was specifically related to symptom levels of GAD, socia

anxiety, OCD, and depression when controlling for the shared

variance among these symptoms. To this end, IUS scores wereregressed on GAD-Q-IV, SPIN, OCI-R, and HADS-D scores entered

simultaneously. Outcomes are summarized in Table 3. Together

these four symptom clusters explained 66.2% of the variance in IUS

scores (F(4, 113) = 53.48,p < 0.001). Levels of social anxiety, GAD

and OCD symptoms, but not the level of depression, were uniquely

related with scores on the IUS.

Hierarchical regression showed that the contribution to the

explained variance in IU, over and above the variance explained by

the other three symptom levels, of social anxiety was 4.9% (Fchange

(1,109) = 15.75,p< 0.001),ofGADwas2.6%(Fchange(1,109) = 8.47

p< 0.01), ofOCD was 6.3%(Fchange (1,109) = 20.38,p< 0.001),and

of depression was 1.2% (Fchange (1, 109) = 3.98, p= 0.05)

Table 2Summary of hierarchical regression analysis predicting Social Phobia Inventory

scores (log)

Variables entered

(in order)

DR2 DF B S.E. B b

Block 1 (enter) EPQ-N 0.38 75.67 0.02 0.01 0.17*

Block 2 (stepwise) BFNE (log) 0.15 38.12 0.63 0.18 0.28**

ASI (log) 0.02 6.19 0.50 0.30 0.15

Block 3 (enter) IUS (log) 0.04 11.71 0.92 0.27 0.31**

Note: ASI = AnxietySensitivityIndex.BFNE = Brief Fearof NegativeEvaluationScale.

EPQ-N = Shortened Eysenck Personality Questionnaire, neuroticism subscale.

IUS = Intolerance of Uncertainty Scale. B s, S.E.s, and b s are from the final step,

whereas DR2 and DFvalues are from each step.* p< 0.05.**

p < 0.01.

Table 3

Summary of hierarchical regression analysis predicting Intolerance of Uncertainty

Scale scores (log)

Variables added B S.E.B b

SPIN 0.10 0.03 0.30*

GAD-Q-IV 0.01 0.004 0.26*

OCI-R 0.42 0.09 0.29*

HADS-D 0.07 0.04 0.15

Note: GAD-Q-IV = Generalized Anxiety Disorder Questionnaire for DSM-IV. HADS-

D = Depression Subscale of Hospital Anxiety and Depression Scale. OCI-R = Revised

Obsessive Compulsive Inventory. SPIN = Social Phobia Inventory.* p< 0.01.**

p < 0.001.

Table 1

Mean scores of variables and spearman correlations among variables

M(S.D.) 1 2 3 4 5 6 7 8 9 10 11 1 2

1 SFI 11.2 (11.2)

2 BFNE 26.2 (12.7) 0.63

3 ASI 25.4 (9.2) 0.64 0.63

4 SES 19.8 (5.1) 0.46 0.47 0.42

5 MPS CM 18.4 (7.3) 0.57 0.68 0.54 0.43

6 MPS D 8.4 (3.1) 0.47 0.57 0.48 0.54 0.707 MPS PC 9.4 (4.3) 0.30 NS 0.33 0.28 NS 0.19 NS 0.55 0.49

8 PSWQ 43.9 (14.2) 0.55 0.58 0.60 0.56 0.45 0.47 0.25 NS

9 GAD-Q-IV 4.9 (3.2) 0.68 0.57 0.68 0.54 0.40 0.39 0.22 NS 0.74

10 OCI-R 9.4 (7.7) 0.46 0.44 0.43 0.40 0.40 0.45 0.17 NS 0.49 0.46

11 HADS-D 4.1 (4.3) 0.48 0.35 0.48 0.59 0.33 0.36 0.15 NS 0.54 0.64 0.38

12 EPQ-N 5.4 (3.7) 0.64 0.48 0.64 0.58 0.42 0.40 0.22 NS 0.75 0.77 0.48 0.64

13 IUS 54.4 (19.9) 0.70 0.59 0.64 0.53 0.53 0.55 0.22 NS 0.75 0.68 0.67 0.58 0.67

Note: All correlations are significant atp < 0.0006 unless otherwise noted. ASI = Anxiety Sensitivity Index. BFNE = Brief Fear of Negative Evaluation scale. EPQ-N = Shortened

Eysenck Personality Questionnaire, neuroticism subscale. GAD-Q-IV = Generalized Anxiety Disorder Questionnaire for DSM-IV. HADS-D = Depression scale of Hospita

Anxiety and Depression Scale. IUS = Intolerance of Uncertainty Scale. MPS CM = Multidimensional Perfectionism Scale Concern over Mistakes. MPS DA = Multidimensiona

Perfectionism Scale Doubts about Actions. MPS PC = Multidimensional Perfectionism Scale Parental Criticism. NS = Not significant. OCI-R = Revised Obsessive Compulsive

Inventory. PSWQ = Penn State Worry Questionnaire. SES = Rosenberg Self-Esteem Scale. SPIN = Social Phobia Inventory.



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4. Discussion

This study had two goals. The first goal was to examine the

association of IU with social anxiety severity, when controlling for

neuroticism and several established correlates of social anxiety

(FNE, anxiety sensitivity, low self-esteem, three aspects of

perfectionism, and pathological worry). The second goal was to

enhance knowledge on the generality vs. specificity of IU byexamining the specificity of the relationship of IU with symptom

levels of GAD, social anxiety, OCD, and depression.

As a first step in our analyses, zero-order correlations of social

anxiety severity with the other indices examined in this study

were calculated (among other correlations). All these correlations,

except the correlation of social anxiety with Parental Criticism (a

component of perfectionism), were significant.1 These findings are

in agreement with earlier studies showing that social anxiety is

correlated with FNE (Weeks et al., 2005), anxiety sensitivity

(Orsillo et al., 1994), low self-esteem (Kocovski & Endler, 2000),

some components of perfectionism (Juster et al., 1996), patholo-

gical worry (Starcevic et al., 2007), and neuroticism (Brown &

Barlow, 2002).

Next, hierarchical regression predicting social anxiety severity

was carried out to examine how much of the variance in social

anxiety severity was explained by IU, when controlling for

neuroticism (entered in block 1 of the regression equation) and

for the aforementioned seven correlates of social anxiety (sub-

jected to a stepwise procedure in block 2). Outcomes showed that

FNE and anxiety sensitivity were the only two cognitive correlates

that were selected into the equation in block 2, explaining 17% of

the variance in social anxiety over and above the 38.1% explained

by neuroticism. Low self-esteem, different aspects of perfection-

ism, and pathological worry were not selected into the equation.

These findings link up with earlier studies that have cast doubts on

the importance of perfectionism in social anxiety (Rosser et al.,

2003). In addition, they show that, although people high in social

anxiety also display elevated levels of pathological worry (cf.

Starcevic et al., 2007) and low self-esteem (Kocovski & Endler,2000), worry and low self-esteem are not specific correlates of

social anxiety, when taking into account other correlates. Most

pertinent to the first goal of this study, IU, added to the equation in

block 3, explained a significant additional 4% of the variance in

social anxiety severity, above and beyond neuroticism, FNE, and

anxiety sensitivity.In thefinal model,neuroticism, FNE, andIU, but

not anxiety sensitivity explained unique variance in social anxiety.

When comparing the relative contribution of FNE and IU to the

explained variance in social anxiety, independent of neuroticism, it

was found that FNE explained 6.6% of the variance in social anxiety

over and above neuroticism and IU. IU explained 5.4% of the

variance in social anxiety over and above neuroticism and FNE.

Altogether, these findings replicate earlier studies which have

shown that FNE is critical to social anxiety (Weeks et al., 2005) andcomplement earlier findings in showing that IU possibly plays an

important role in social anxiety as well.

To achieve our second goal, levels of IU were regressed on

symptom levels of social anxiety, GAD, OCD, and depression.

Outcomes showed that, after controlling for the shared variance

among the symptom clusters, GAD, social anxiety, and OCD, but

not depression were uniquely related with IU. When comparing

the relative contribution of symptom clusters to the explained

variance in IU, OCD severity was found to have the strongest link

with IU, followed by social anxiety, GAD, and depression.

Altogether, these findings link up with earlier findings that IU is

specific for GAD and OCD (Holaway et al., 2006) but not fordepression (Dugas et al., 2004). Importantly, the present findings

add to earlier studies in showing that IU is also specifically related

to social anxiety.

Several limitations should be kept in mind when interpreting

outcomes of this study. A first limitation is that the cross-sectional

design precludes any conclusions about causality. Thus, the degree

to which IU is causally related to the development and

maintenance of social anxiety awaits further examination. A

second limitation concerns the composition of the sample. The

sample included self-selected, predominantly relatively highly

educated people with internet access, most of whom were female.

This restricts the generalizability of the results and comparability

with other samples. Moreover, all participants had suffered the

death of a relative. Although one could argue that specific aspects

of the participants mourning may have affected the current

results, this seems unlikely given that losses occurred at least 18

months prior to this study and, more importantly, depression

severity was at a non-clinical level. Nevertheless, conclusions of

this study must remain tentative pending replication with other

samples. A third limitation is that we administered a relatively

large number of questionnaires. This may have lowered the

response rate and may have been tiring to the people who

participated. A fourth limitation is that we only examined the

association of IU with four clinical phenomena (i.e., symptoms of

GAD, social anxiety, OCD, depression). It would be relevant for

future studies to assess a wider range of clinical symptoms in the

context of a single study to further examine the specificity of IU to

different psychological disorders.

Notwithstanding these limitations, the current study adds toour knowledge of factors contributing to social anxiety severity

and the specificity vs. generality of IU. At the very least, findings

indicate that a more comprehensive examination of the role of IU

in social anxiety is warranted. Cognitive behavioral models of

social anxiety suggest that safety behaviors and self-focused

attention play a key role in social anxiety (Clark & Wells, 1995;

Rapee & Heimberg, 1997). Among other things, it would be

interesting for future studies to explore how IU works together

with these maladaptive behaviors in maintaining social anxiety.

One might speculate that, in some way, these behaviors serve to

decrease the presumably unbearable feelings of uncertainty in

social-evaluative situations, in the same way that worrying serves

to reduce the uncertainty that GAD patients experience when a

potential future catastrophe comes to mind. With respect to thegenerality vs. specificity of IU, several challenging research

questions remain as well. For instance, if future studies confirm

that IU is related to differentpsychological disordersand notjust to

GAD, it becomes importantto identify factors that contribute to the

differential development of GAD, OCD, or social anxiety among

those with elevated levels of IU.

If future studies show that IU is causally related to social

anxiety, this would have clinical implications. For instance, it

would suggest that augmenting peoples tolerance for the

uncertainty that is inherent to many social-evaluative situations

is a potentially fruitful intervention in the treatment of social

anxiety. Currently, effective treatments of social anxiety mostly

target self-focused attention, avoidance and safety behaviors, FNE,

and distorted self-imagery, using interventions such as cognitive

1 Although one could argue that it is very logical that FNE and social anxiety

severity are correlated because there is conceptual overlap between both concepts,

it is important to note that several authors have claimed that the concepts are

related, but distinct. For instance, Weeks et al. (2005, p. 179) state that fear of

negative evaluation pertains to the sense of dread associated with being evaluated

unfavorably while anticipating or participating in a social situation, whereas social

anxiety pertains to affective reactions to these situations. Indeed, examination of the

items of the BFNE and SPIN used in this study revealed little item content overlap,

suggesting thatthe strong correlation betweenthe measuresis not justthe result of

confounds in content.

P.A. Boelen, A. Reijntjes/ Journal of Anxiety Disorders 23 (2009) 130135134


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restructuring, task concentration training, and exposure (Mulkens,

Bogels, de Jong, & Louwers, 2001), as well as experiential exercises

and video feedback training (Clark et al., 2006). It would be

interesting for future studies to examine the effect of directly

targeting IU on the severity of social anxiety symptoms. The work

of Dugas and coworkers indicate that IU can be successfully curbed

using specific cognitive behavioral interventions such as problem

orientation training and exposure to uncertainty (e.g., Dugas &Ladouceur, 2000). Among other things, one might speculate that

repeated imaginal exposure to fear-evoking social scenarios that

include different elements of uncertainty may help to increase

tolerance for the uncertainty that is inherent to many social-

evaluative situations and, along that pathway, reduce social

anxiety. More research on the role of IU in social anxiety is likely

to augment current approaches to theassessment andtreatment of

this prevalent, debilitating clinical phenomenon.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mentaldisorders(4th ed.). Washington, DC: American Psychiatric Association.

Boelen, P. A., & van den Hout, M. A. (2008). The role of threatening misinterpretationsand avoidance in emotional problems after loss. Behavioural and Cognitive Psy-

chotherapy, 36, 7188.Bogels, S. M. (2004). De Nederlandstalige Fear of Negative Evaluation Scale [Dutch version

of the Fear of Negative Evaluation Scale]. Maastricht: Vakgroep Differentiele enExperimentele Psychologie.

Brown, T.A., & Barlow, D. H.(2002). Classificationof anxiety andmooddisorders.In: D.H. Barlow (Ed.), Anxiety and its disorders: the nature and treatment of anxiety and

panic(2nd ed., pp. 292327). New York, NY: Guilford Press.Buhr, K., & Dugas, M. J. (2002). The Intolerance of Uncertainty Scale: psychometric

properties of the English version. Behaviour Research and Therapy, 40, 931945.Clark, D. M., Ehlers, A., McManus, F., Fennell, M., Grey, N., Waddington, L., et al. (2006).

Cognitive therapy versus exposure and applied relaxation in social phobia:a rando-mised controlled trial. Journal of Consulting and Clinical Psychology, 74, 568578.

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In: R. G. Heimberg,M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: diagnosis,assessment, and treatment(pp. 6993). New York: Guilford Press.

Connor, K. M., Davidson, J. R. T., Churchill, L. E., Sherwood, A., Foa, E., & Weisler, R. H.(2000). Psychometric properties of the Social Phobia Inventory (SPIN). British

Journal of Psychiatry, 176, 379386.Cordova-Middelbrink,J. A.,Dek,E. C.P., & Engelbarts,M. M.B. (2007).Automatisering bij

subklinische obsessief-compulsieve stoornis [automatic processes in subclinical obses-sive compulsive disorder]. Unpublished master thesis. Utrecht: Utrecht University.

De Bruin, G. O., Rassin, E., van der Heiden, C., & Muris, P. (2006). Psychometricproperties of a Dutch version of the Intolerance of Uncertainty Scale. Netherlands

Journal of Psychology, 62, 9197.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., Marchand, A., & Ladouceur, R. (2005). Further validation of a cognitive-

behavioral model of generalized anxiety disorder: diagnostic and symptom spe-cificity. Journal of Anxiety Disorders, 19, 329343.

Dugas, M. J., Schwarzt, A., & Francis, K. (2004). Intolerance of uncertainty, worry, anddepression.Cognitive Therapy and Research, 28, 835842.

Eysenck, S. B. G., Eysenck, H. J., & Barrett, P. (1985). A revised version of the psychoti-cism scale. Personality and Individual Differences, 6, 2129.

Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., et al. (2002). TheObsessive-Compulsive Inventory: development and validation of a short version.Psychological Assessment, 14, 485496.

Franck, E., De Raedt, R., Barbez, C., & Rosseel, Y. (in press). Psychometric properties of

the Dutch Rosenberg self-esteem scale. Psychologica Belgica.Freeston, M. H., Rheaume, J., Letarte, H., Dugas, M. J., & Ladouceur, R. (1994). Why do

people worry? Personality and Individual Differences, 17, 791802.Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfec-

tionism.Cognitive Therapy and Research, 14, 449468.Hajcak, G., Huppert, J. D., Simons, R. F., & Foa, E. B. (2004). Psychometric properties of

the OCI-R in a college sample.Behaviour Research and Therapy, 42, 115123.

Hofmann, S. G., & Barlow, D. H. (2002). Social phobia (social anxiety disorder). In: D. HBarlow (Ed.),Anxiety and its disorders: the nature and treatment of anxiety and panic(2nd ed., pp. 454476). New York, NY: Guilford Press.

Holaway, R. M., Heimberg, R. G., & Coles, M. E. (2006). A comparison of intolerance ouncertainty in analogue obsessive-compulsive disorder and generalized anxietydisorder. Journal of Anxiety Disorders, 20, 157174.

Juster, H., Heimberg, R., Frost, R., Holt, C., Mattia, J., & Faccenda, K. (1996).Perfectionismand social phobia. Personality and Individual Differences, 21, 403410.

Kessler,R. C., Berglund,P.,Demler,O., Jin, R.,& Walters,E. E.(2005).Lifetimeprevalenceand age-of-onset distributions of DSM-IV disorders in the National Comorbidity

Survey Replication. Archives of General Psychiatry, 62, 593602.Kocovski, N. L., & Endler, N. S. (2000). Social anxiety, self-regulation, and fear o

negative evaluation. European Journal of Personality, 14, 347358.Ladouceur, R., Dugas, M. J., Freeston, M. H., Rheaume, J., Blais, F., Boisvert, J., et al

(1999). Specificity of generalized anxiety disorder symptoms and processesBehaviour Research and Therapy, 30, 191207.

Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development andvalidation of the Penn State Worry Questionnaire.Behaviour Research and Therapy

28, 487495.Mineka, S.,Watson, D.,& Clark,L. A. (1998). Comorbidityof anxiety andunipolar mood

disorders.Annual Review of Psychology, 49, 377412.Mulkens, S., Bogels, S. M., de Jong, P. J., & Louwers, J. (2001). Fear of blushing: effects o

task concentrationtrainingversus exposure in vivoon fear and physiology.Journaof Anxiety Disorders, 15, 413432.

Newman, M. G., Zuelling, A. R., Kachin, K. E.,Constantino,M. J., Przeworski, A., EricksonT.,et al.(2002). Preliminary reliability andvalidityof theGAD-Q-IV: a revised selfreport diagnostic measure of generalized anxiety disorder. Behavior Therapy, 33215233.

Orsillo, S. M., Lilienfeld, S. O., & Heimberg, R. G. (1994). Social phobia and response tochallenge procedures: examining the interaction between anxiety sensitivity andtrait anxiety. Journal of Anxiety Disorders, 8, 247258.

Peterson, R. A., & Reiss, S. (1992).Anxiety sensitivity index manual (2nd ed.). Worthington, OH: International Diagnostic Systems.

Rapee, R. M.,& Heimberg,R. G. (1997).A cognitive-behavioralmodel of anxiety insociaphobia.Behaviour Research and Therapy, 35, 741756.

Rijsoort, S. N., van Emmelkamp, P. M. G., & Vervaeke, G. A. C. (1999). The Penn StateWorry Questionnaireand the Worry Domains Questionnaire: structure,reliabilityand validity. Clinical Psychology and Psychotherapy, 6, 297307.

Rosenberg, M. (1989).Society and the adolescent self-image(Rev. ed.). Middletown, CTWesleyan University Press.

Rosser, S., Issakidis, C., & Peters, L. (2003). Perfectionism in social phobia: relationshipbetween the constructs and impact on cognitive behaviour therapy. CognitiveResearch and Therapy, 27, 143151.

Sanderman, R., Arrindell, W. A., Ranchor, A. V., Eysenck, H. J., & Eysenck, S. B. G. (1995)Het meten van persoonlijkheidskenmerken met de Eysenck Personality Questionnaire(EPQ), een handleiding [measuring personality characteristics using the EysenckPersonality Questionnaire (EPQ), a manual]. Groningen: Noordelijk Centrum voo

Gezondheidsvraagstukken.Spinhoven, P., Ormel, J., Sloekers, P. P. A., Kempen, G. I. J. M. , Speckens, A. E. M., &

Hemert van, A. M. (1997). A validation of the Hospital Anxiety and DepressionScale (HADS) in different groups of Dutch subjects. Psychological Medicine, 27363370.

Starcevic, V., & Berle, D. (2006). Cognitive specificity of anxiety disorders: a review ofselected key constructs. Depression and Anxiety, 23, 5161.

Starcevic, V., Berle, D., Milicevic, D., Hannan, A., Lamplugh, C., & Eslick, G. (2007)Pathological worry, anxiety disorders and the impact of co-occurrence withdepressive and other anxiety disorders. Journal of Anxiety Disorders, 21, 101610127.

Steketee, G., Frost, R. O., & Cohen, I. (1998). Beliefs in obsessive compulsive disorderJournal of Anxiety Disorders, 12, 525537.

Tolin, D.F., Abramowitz,J. S.,Brigidi, B., & Foa, E.B. (2003).Intoleranceof uncertaintyinobsessive-compulsive disorder. Journal of Anxiety Disorders, 17, 233242.

Vujanovic, A. A., Arrindell, W. A., Bernstein, A., Norton, P. J., & Zvolensky, M. J. (2007)Sixteen-item Anxiety Sensitivity Index. Confirmatory factor analytic evidenceinternal consistency, and construct validity in a young adult sample from TheNetherlands.Assessment, 14, 129143.

Weeks, J. W., Heimberg, R. G., Fresco, D. M., Hart, T. A., Turk, C. L., & Schneier, et al(2005). Empirical validation and psychometric evaluation of the brief fear onegative evaluation scale in patients with social anxiety disorders. Psychologica

Assessment, 17, 179190.Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta

Psychiatrica Scandinavica, 67, 361370.


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