Intolerance of Uncertainty Therapy for Generalized Anxiety Disorder

Overcome GAD by learning to tolerate uncertainty.
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Generalized anxiety disorder (GAD) involves chronic, excessive, and uncontrollable worry about a range of everyday problems. Unlike other anxiety disorders that involve specific types of fears, such as the fear of negative evaluation in social anxiety disorder, and the fear of escalating physical symptoms in panic disorder, the fear in GAD is more difficult to pinpoint.

Intolerance of Uncertainty in GAD

To address this gap in understanding fears in generalized anxiety disorder, researchers in Quebec, Canada developed a model in the early 1990s.

Developed by Michel Dugas and Robert Ladouceur, this model consists of four components.

The most important component is known as intolerance of uncertainty, and is thought of as a higher-order process that leads directly to worry through three other processes:

1. Positive beliefs about worry: Believing that worry is beneficial. In this context, worrying is a way to gain certainty.

2. Negative problem orientation: Feeling helpless and hopeless to solve problems, viewing problems as threatening, or as barriers or obstacles, and doubting one's ability to solve problems.

3. Cognitive avoidance: Feeling that problems should be dealt with only when necessary.

People with GAD are thought to be higher in intolerance of uncertainty than those with other anxiety disorders. They have a belief system in which uncertainty is viewed as stressful, unfair, upsetting, and to be avoided.

In this model, when you worry, you are attempting to reduce feelings of uncertainty.

If you worry that you might be late for an appointment, you will leave much earlier than necessary to be absolutely certain you will get there on time.

Since it is the uncertainty of events, and not some aspect of them in particular that triggers your worry, what you worry about through the day will change.

In the morning, you might be worried about making it to a dentist appointment on time, while by evening you could be fretting about making a decision over which cell phone plan to choose.

In this way, worry is a tactic you use to try and mentally plan and prepare for any possible outcome, especially the bad ones. However, the worry in generalized anxiety disorder can be so severe that it becomes a problem itself.

Are You Intolerant of Uncertainty?

The following thoughts and behaviors reflect intolerance of uncertainty. Ask yourself if any of these apply to you:

  • You look for information and solutions to every possible problem you may face.
  • You worry about things even if the odds of them happening is very low (e.g., being in a plane crash, being diagnosed with cancer).
  • You require perfect solutions that must have a 100 percent chance of working.
  • You seek reassurance from others that everything will be okay, and get second and third opinions on medical matters.
  • You make lists, double-check, refuse to delegate tasks, or over-prepare to manage uncertainty.
  • You think that uncertainty means something bad will happen.
  • You feel it is irresponsible or dangerous for there to be uncertainty in your life.
  • You avoid new situations out of fear of uncertainty.
  • You procrastinate, keep predictable routines, or ask others to make decisions for you.
  • You feel that you can't tolerate not knowing the outcome of a situation.
  • You feel that you would rather know for sure the outcome of a situation will be bad, than be left not knowing the outcome.

Intolerance of Uncertainty Therapy for Generalized Anxiety Disorder

Those same researchers in Canada realized that changes in intolerance of anxiety precede changes in worry in treatment for GAD.

This led them to suggest treatment that targets intolerance of uncertainty for these individuals.

The goal of this type of treatment is to help individuals become more tolerant of uncertainty. This type of therapy can take different forms and involve different components:

1. Identifying situations and strategies

Individuals are taught how to identify problems that they can solve versus those that are outside of their control, and the strategies that can be used for each. 

2. Behavioral experiments

Behavioral experiments involve testing out feared predictions. The individual is asked to write down the following three aspects of a situation:

  • Feared outcome
  • Actual outcome
  • Coping response

For example, a person might choose to do a behavioral experiment about choosing a restaurant for dinner. Your feared outcome might be that you won't like the food. You would then record the actual outcome (either you did or did not like it) and your coping response. If you liked the food, there would be no coping response recorded. If, however, you did not like the food, you might write down something like "I had something else to eat when I got home" or "I was quite upset with myself for having chosen the wrong restaurant."

Over time, the goal of the behavioral experiments is to move from small events to larger ones, across multiple settings (work, home, social settings) and to observe that in most uncertain situations, the outcome is tolerable, and when it is not, that it can be managed.

Help Yourself Overcome Intolerance of Uncertainty

What if you think to yourself, "Well that's fine, but I really can't deal with the uncertainty of not liking the food at a new restaurant. I'd rather just stick to what I know"?

Ask yourself this: Are there any advantages to accepting some uncertainty?

Some you might identify include:

  • Feeling less anxious and worried
  • Having new experiences and taking on new challenges
  • Having time to focus on solving real problems instead of worrying about ones that may never happen

If these reasons are important to you, you can move toward accepting uncertainty by practicing behavioral experiments on your own to test out your feared outcomes, distancing yourself from your anxious thoughts, and practicing staying in the moment.

For example, realize that your thoughts are just thoughts, and that you don't have to react. You might think "Well, this could be the day the plane crashes." Then, think, that's an interesting thought, and let it float away. Don't react to it, just realize it is only a thought. Keep letting it float by until your anxiety subsides.

Practice mindful breathing, and stay in the moment.

Remember that your coping responses prevent you from seeing that there really was no purpose to your worry in the first place. If you always leave for appointments an hour early, you will never learn how much time you really need to allocate to get there on time.

The key is to experience uncertainty rather than to avoid it in everyday life. Learning to tolerate and deal with uncertainty is key to decreasing your worry and anxiety.

Sources:

Boswell JF, Thompson-Hollands J, Farchione TJ, Barlow DH. Intolerance of Uncertainty: A Common Factor in the Treatment of Emotional Disorders. J Clin Psychol. 2013;69(6). doi:10.1002/jclp.21965.

Dugas MJ, Ladouceur R. Treatment of GAD. Targeting intolerance of uncertainty in two types of worry. Behav Modif. 2000;24(5):635-657. doi:10.1177/0145445500245002.

Leahy RL. "But what if I'm THE ONE?" How Intolerance of Uncertainty Makes you Anxious. Psychology Today Online; May 14, 2008.

Robichaud M. Bringing Specificity to Generalized Anxiety Disorder: Conceptualization and Treatment of GAD Using Intolerance of Uncertainty as the Theme of Threat. ADAA; April 2013.

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