R. Nicholas Carleton

Increasingly certain about uncertainty: Intolerance of uncertainty across anxiety and depression.

Intolerance of uncertainty (IU) - a dispositional characteristic resulting from negative beliefs about uncertainty and its implications - may be an important construct in anxiety disorders and depression. Despite the potential importance of IU, clinical data on the construct remains relatively scant and focused on generalized anxiety disorder and obsessive-compulsive disorder. The present study systematically investigated IU, as measured by the Intolerance of Uncertainty Scale-12 (IUS-12), across groups diagnosed with anxiety disorders (i.e., social anxiety disorder, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder) or depression (clinical sample: n=376; 61% women), as well as undergraduate (n=428; 76% women) and community samples (n=571; 67% women). Analysis of variance revealed only one statistically significant difference in IUS-12 scores across diagnostic groups in the clinical sample; specifically, people with social anxiety disorder reported higher scores (p<.01; η(2)=.03) than people with panic disorder. People diagnosed with an anxiety disorder or depression reported significantly and substantially higher IUS-12 scores relative to community and undergraduate samples. Furthermore, IUS-12 score distributions were similar across diagnostic groups as demonstrated by Kernel density estimations, with the exception of panic disorder, which may have a relatively flat distribution of IU. Response patterns were invariant across diagnostic groups as demonstrated by multi-group confirmatory factor analyses, but varied between clinical and nonclinical samples. Overall, the findings suggest IU may serve as an important transdiagnostic feature across anxiety disorders and depression. In addition, robust support was found for the proposed 2-factor model of the IUS-12. Comprehensive findings, implications, and future research directions are discussed.

The intolerance of uncertainty construct in the context of anxiety disorders: theoretical and practical perspectives

Modern anxiety disorder models implicitly include intolerance of uncertainty (IU) as a critical component for the development and maintenance of these pervasive social and economic concerns. IU represents, at its core, fear of the unknown – a long-recognized, deep-seated fear identified in normative and pathological samples. Indeed, the intrinsic nature of IU can be argued as evolutionarily supported, a notion buttressed by initial biophysiological evidence from uncertainty-related research. Originally thought to be specific to generalized anxiety disorder, recent research has clearly demonstrated that IU is a broad transdiagnostic dispositional risk factor for the development and maintenance of clinically significant anxiety. The available evidence suggests that theorists, researchers and clinicians may benefit from explicitly incorporating IU into models, research designs, case conceptualizations and as a treatment target.

“It's not just the judgements—It's that I don’t know”: Intolerance of uncertainty as a predictor of social anxiety

Interest in the role of intolerance of uncertainty (IU) - the tendency for a person to consider the possibility of a negative event occurring as unacceptable and threatening irrespective of the probability of its occurrence - in anxiety disorders has been increasing in recent research. IU has been implicated as an important construct associated with generalized anxiety disorder (GAD); however, a growing body of research suggests that levels of IU are also high among individuals with other anxiety disorders. Despite the increasing interest, few studies have examined the relationship between IU and social anxiety (SA). The purpose of the present investigation was to further investigate the relationship between IU and SA. Participants included 286 community members (71% women) from Canada who completed measures of IU, SA, anxiety sensitivity, and fear of negative evaluation (FNE). Regression analyses revealed that the inhibitory anxiety dimension of IU, the fear of socially observable anxiety symptoms dimension of anxiety sensitivity, and the FNE were consistently significant predictors of SA symptoms. Unexpectedly, IU and FNE were often comparable predictors of SA variance. Moreover, participants with SA symptoms consistent with SAD exhibited levels of IU comparable to those reported by participants with worry symptoms consistent with GAD. Comprehensive findings, implications, and directions for future research are discussed.

The Center for Epidemiologic Studies Depression Scale: A Review with a Theoretical and Empirical Examination of Item Content and Factor Structure

Background The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) is a commonly used freely available self-report measure of depressive symptoms. Despite its popularity, several recent investigations have called into question the robustness and suitability of the commonly used 4-factor 20-item CES-D model. The goal of the current study was to address these concerns by confirming the factorial validity of the CES-D. Methods and Findings Differential item functioning estimates were used to examine sex biases in item responses, and confirmatory factor analyses were used to assess prior CES-D factor structures and new models heeding current theoretical and empirical considerations. Data used for the analyses included undergraduate (n = 948; 74% women), community (n = 254; 71% women), rehabilitation (n = 522; 53% women), clinical (n = 84; 77% women), and National Health and Nutrition Examination Survey (NHANES; n = 2814; 56% women) samples. Differential item functioning identified an item as inflating CES-D scores in women. Comprehensive comparison of the several models supported a novel, psychometrically robust, and unbiased 3-factor 14-item solution, with factors (i.e., negative affect, anhedonia, and somatic symptoms) that are more in line with current diagnostic criteria for depression. Conclusions Researchers and practitioners may benefit from using the novel factor structure of the CES-D and from being cautious in interpreting results from the originally proposed scale. Comprehensive results, implications, and future research directions are discussed.

Addressing revisions to the Brief Fear of Negative Evaluation scale: measuring fear of negative evaluation across anxiety and mood disorders.

The fear of negative evaluation (FNE) represents a fundamental component of social anxiety and social anxiety disorder (SAD) within modern cognitive-behavioral models (Clark & Wells, 1995; Rapee & Heimberg, 1997). As such, access to comprehensive psychometrics for measures of FNE is an important component of thorough clinical and research efforts. Among the most popular measures of FNE have been variations of the 12-item Brief Fear of Negative Evaluation (BFNE) scale (Leary, 1983). There are currently three versions of the BFNE based on two psychometric studies (i.e., two 8-item variants and a 12-item variant). There is still substantial debate regarding which of the three alternatives should be used by researchers and clinicians. Normative data for each of the three alternatives are not available across samples of individuals with diagnosed anxiety and mood disorders; moreover, there has been no comparative assessment of responses for such samples. The present investigation was to provide more definitive recommendations about the three alternatives, to provide normative clinical data, and to explore differences in FNE endorsement across anxiety and mood disorders. Clinical participants included 381 individuals (60% women; age M=35.61, SD=12.49) from an established anxiety treatment and research center. Diagnoses included those with a principal diagnosis of SAD (32%), those with a diagnosis of SAD as an additional disorder (24%), those without a diagnosis of SAD (41%), and those with features of SAD (3%). Results of descriptive analyses, factor analyses, analysis of variance, and receiver operating curves demonstrated that the 12-item variant of the BFNE was inferior or comparable to the two 8-item variants. FNE scores were consistently higher among all participants with a diagnosis of SAD (either principal or additional) relative to all other diagnostic groups (p<.05). Accordingly, the current evidence, as well as parsimony and previous research, supports the utility of the 8-item variant that includes only the original straightforwardly worded items from the BFNE. Comprehensive findings, implications, and future research directions are discussed.

Dot-probe evaluation of selective attentional processing of pain cues in patients with chronic headaches

&NA; Evidence supporting the notion that patients with chronic pain are characterized by attentional biases for sensory and affect pain words, and that such biases are mediated by fear of pain, is mixed. The present investigation was an attempt to replicate and extend initial findings obtained with the dot‐probe task. Thirty patients with chronic headache and 19 healthy controls were tested using a dot‐probe task including affect pain, sensory pain, and neutral words. Individual difference variables, including fear of pain measures, were assessed and considered in analyses. Selective attention was denoted using the bias index, congruency index, and incongruency index. There were no significant between‐group differences or interactions between group and word type observed for any of the indices of selective attention. Across groups there was evidence for a significant association between anxiety sensitivity and the bias index for sensory pain words, and between affective description of current pain and the incongruency index for affect pain words. These results do not provide convincing evidence that patients with chronic headache selectively attend to affect or sensory pain cues when compared to healthy controls. The significant cross‐groups associations between anxiety sensitivity and current pain description and indices of selective attention are consistent with the notion that attentional biases may be influenced by fear propensity and current concerns. Implications of the findings and future research directions are discussed.

Into the unknown: A review and synthesis of contemporary models involving uncertainty

The current review and synthesis serves to define and contextualize fear of the unknown relative to related constructs, such as intolerance of uncertainty, and contemporary models of emotion, attachment, and neuroticism. The contemporary models appear to share a common core in underscoring the importance of responses to unknowns. A recent surge in published research has explored the transdiagnostic impact of not knowing on anxiety and related pathologies; as such, there appears to be mounting evidence for fear of the unknown as an important core transdiagnostic construct. The result is a robust foundation for transdiagnostic theoretical and empirical explorations into fearing the unknown and intolerance of uncertainty.

Refining and validating the Social Interaction Anxiety Scale and the Social Phobia Scale.

Background: The Social Interaction Anxiety Scale and Social Phobia Scale 6 are companion measures for assessing symptoms of social anxiety and social phobia. The scales have good reliability and validity across several samples, 3 , 6 however, exploratory and confirmatory factor analyses have yielded solutions comprising substantially different item content and factor structures. These discrepancies are likely the result of analyzing items from each scale separately or simultaneously. The current investigation sets out to assess items from those scales, both simultaneously and separately, using exploratory and confirmatory factor analyses in an effort to resolve the factor structure. Methods: Participants consisted of a clinical sample (n5353; 54% women) and an undergraduate sample (n5317; 75% women) who completed the Social Interaction Anxiety Scale and Social Phobia Scale, along with additional fear‐related measures to assess convergent and discriminant validity. Results: A three‐factor solution with a reduced set of items was found to be most stable, irrespective of whether the items from each scale are assessed together or separately. Items from the Social Interaction Anxiety Scale represented one factor, whereas items from the Social Phobia Scale represented two other factors. Conclusion: Initial support for scale and factor validity, along with implications and recommendations for future research, is provided. Depression and Anxiety, 2009.

Pain-related anxiety and anxiety sensitivity across anxiety and depressive disorders

Fear-anxiety-avoidance models posit pain-related anxiety and anxiety sensitivity as important contributing variables in the development and maintenance of chronic musculoskeletal pain [Asmundson, G. J. G, Vlaeyen, J. W. S., & Crombez, G. (Eds.). (2004). Understanding and treating fear of pain. New York: Oxford University Press]. Emerging evidence also suggests that pain-related anxiety may be a diathesis for many other emotional disorders [Asmundson, G. J. G., & Carleton, R. N. (2005). Fear of pain is elevated in adults with co-occurring trauma-related stress and social anxiety symptoms. Cognitive Behaviour Therapy, 34, 248-255; Asmundson, G. J. G., & Carleton, R. N. (2008). Fear of pain. In: M. M. Antony & M. B. Stein (Eds.), Handbook of anxiety and the anxiety disorders (pp. 551-561). New York: Oxford University Press] and appears to share several elements in common with other fears (e.g., anxiety sensitivity, illness/injury sensitivity, fear of negative evaluation) as described by Reiss [Reiss, S. (1991). Expectancy model of fear, anxiety, and panic. Clinical Psychology Review, 11, 141-153] and Taylor [Taylor, S. (1993). The structure of fundamental fears. Journal of Behavior Therapy and Experimental Psychiatry, 24, 289-299]. The purpose of the present investigation was to assess self-reported levels of pain-related anxiety [Pain Anxiety Symptoms Scale-Short Form; PASS-20; McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research and Management, 7, 45-50] across several anxiety and depressive disorders and to compare those levels to non-clinical and chronic pain samples. Participants consisted of a clinical sample (n=418; 63% women) with principal diagnoses of a depressive disorder (DD; n=22), panic disorder (PD; n=114), social anxiety disorder (SAD; n=136), obsessive-compulsive disorder (OCD; n=86), generalized anxiety disorder (GAD; n=46), or specific phobia (n=14). Secondary group comparisons were made with a community sample as well as with published data from a treatment-seeking chronic pain sample [McCracken, L. M., & Dhingra, L. (2002). A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research and Management, 7, 45-50]. Results suggest that pain-related anxiety is generally comparable across anxiety and depressive disorders; however, pain-related anxiety was typically higher (p<.01) in individuals with anxiety and depressive disorders relative to a community sample, but comparable to or lower than a chronic pain sample. Results imply that pain-related anxiety may indeed be a construct independent of other fundamental fears, warranting subsequent hierarchical investigations and consideration for inclusion in treatments of anxiety disorders. Additional implications and directions for future research are discussed.

Human tonic immobility: measurement and correlates

Background: Tonic immobility (TI) is a temporary state of motor inhibition believed to be a response to situations involving extreme fear. Limited attention has been directed to studying TI in humans; however, the phenomenon has been well documented in the animal literature. In humans, TI is believed to occur during sexual assault, and there have been reports of fear‐induced freezing in the contexts of air, naval, and other disasters. Methods: This study had three main purposes: (1) to assess the factor structure of a new self‐report measure—the Tonic Immobility Questionnaire 1 —designed to assess human TI in a range of traumatic events; (2) to explore associations among discovered TIQ factors and a measure of posttraumatic symptoms in the context of trauma type; and (3) to determine whether TI is related to suspected and empirically supported predictors of posttraumatic stress disorder. Participants were a subset of undergraduate students (n=78) who reported a TI experience in the context of a traumatic event. Results: No differences were found in frequency or severity of TI reported across trauma types. Exploratory factor analysis of Tonic Immobility Questionnaire item responses resulted in a three‐factor solution (i.e., physical immobility, fear, and dissociation). Significant positive correlations were found between the Tonic Immobility Questionnaire and measures of posttraumatic symptoms, dissociation, anxiety sensitivity, and absorption. Regression analysis revealed that peritraumatic dissociation scores alone accounted for 51% of the variance in TI scores. Conclusions: TI may represent an extreme behavioral expression of trauma‐induced peritraumatic dissociation. Implications and directions for future research are discussed. Depression and Anxiety, 2009.© 2009 Wiley‐Liss, Inc.