J. Behav. Ther. & Exp. Psychiat. 43 (2012) 849e854
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Changes in intolerance of uncertainty during cognitive behavior group therapy for social phobia Alison E.J. Mahoney a, *, Peter M. McEvoy b, c a
Clinical Research Unit for Anxiety and Depression, University of New South Wales at St Vincent’s Hospital, Level 4 O’Brien Centre, 394-404 Victoria Street, Darlinghurst, Sydney, New South Wales 2010, Australia b Centre for Clinical Interventions, 223 James Street, Northbridge, Perth, Western Australia 6003, Australia c School of Psychology, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia 6009, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 October 2011 Received in revised form 7 December 2011 Accepted 7 December 2011
Background and objectives: Recent research suggests that intolerance of uncertainty (IU), most commonly associated with generalized anxiety disorder, also contributes to symptoms of social phobia. This study examines the relationship between IU and social anxiety symptoms across treatment. Method: Changes in IU, social anxiety symptoms, and depression symptoms were examined following cognitive behavior group therapy (CBGT) for social phobia (N ¼ 32). Results: CBGT led to significant improvements in symptoms of social anxiety and depression, as well as reductions in IU. Reductions in IU were associated with reductions in social anxiety but were unrelated to improvements in depression symptoms. Reductions in IU were predictive of post-treatment social phobia symptoms after controlling for pre-treatment social phobia symptoms and changes in depression symptoms following treatment. Limitations: The relationship between IU and social anxiety requires further examination within experimental and longitudinal designs, and needs to take into account additional constructs that are thought to maintain social phobia. Conclusions: Current findings suggest that the enhancing tolerance of uncertainty may play a role in the optimal management of social phobia. Theoretical and clinical implications are discussed. Ó 2011 Elsevier Ltd. All rights reserved.
Keywords: Intolerance of uncertainty Social phobia Depression Cognitive behavior therapy
1. Introduction Individuals with social phobia fear negative evaluation in social and performance situations; they frequently avoid these situations or endure then with considerable distress (American Psychiatric Association, APA, 2000). Intolerance of uncertainty (IU) has been conceptualized as a cognitive bias that influences how individuals perceive, interpret, and react to uncertain situations (Dugas, Schwartz, & Francis, 2004). For individuals who are high in IU, the possibility that negative future events may occur is threatening and unacceptable, regardless of the probability of such events actually occurring (Ladouceur, Gosselin, & Dugas, 2000). As a consequence, they tend to respond to uncertain situations with distress and seek to avoid them (Buhr & Dugas, 2002). Social and performance situations, such as meeting unfamiliar people or public speaking,
* Corresponding author. Tel.: þ612 8382 1407; fax: þ612 8382 1402. E-mail addresses:
[email protected] (A.E.J. Mahoney),
[email protected] (P.M. McEvoy). 0005-7916/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2011.12.004
peter.
inherently involve a degree of uncertainty, and some researchers have speculated that the ability to tolerate uncertainty in social situations may be a critical element in the development and maintenance of social anxiety symptoms (Carleton, Collimore, & Asmundson, 2010). IU has been explored within a variety of internalizing disorders, although it has been most heavily associated with worry and generalized anxiety disorder (GAD; Dugas, Gagnon, Ladouceur, & Freeston, 1998; van der Heiden et al., 2010; Sexton, Norton, Walker, & Norton, 2003). Although excessive worry is the hallmark of GAD, elevated worry is a common feature of many internalizing disorders (Harvey, Watkins, Mansell, & Shafran, 2004) and recent conceptualizations of IU suggest that it may be a transdiagnostic construct (Starcevic & Berle, 2006). IU appears to contribute to symptoms of many anxiety and depressive disorders. For example, McEvoy and Mahoney (2011) reported that IU accounted for unique variance in symptoms of GAD, obsessive compulsive disorder (OCD), panic disorder and agoraphobia, social phobia, and depression. Mahoney and McEvoy (2011a) have also shown that levels of IU did not significantly vary across patients with GAD, social phobia, panic
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disorder with or without agoraphobia, OCD, or depression. Moreover, in a pooled community and clinically anxious sample, IU has been shown to demonstrate a continuous or dimensional latent structure (Carleton et al., 2011). Thus IU may be potentially relevant to our understanding of multiple anxiety disorders. This paper specifically concerns the relationship between IU and social phobia. Currently, IU does not play a substantial role in cognitive models of the maintenance and development of social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997). However, there is evidence to suggest that IU contributes to social anxiety symptoms. In a nonclinical sample, Boelen and Reijntjes (2009) found that IU explained a significant proportion of variance in social anxiety symptoms after taking account of neuroticism and a number of cognitive factors such as fear of negative evaluation, anxiety sensitivity, low selfesteem, perfectionism, and worry. Social anxiety symptoms were also predictive of IU after controlling for the shared symptom variance associated with GAD, OCD, and depression. IU has also been found to be positively associated with changes in social anxiety over a subsequent one week period (Riskind, Tzur, Williams, Mann, & Shahar, 2007). People with social phobia also appear to report the same level or degree of IU as people with GAD (Carleton et al., 2010; Mahoney & McEvoy, 2011a). Recent studies have examined different components of IU and their relationships to social phobia symptoms. Carleton, Norton, and Asmundson (2007) identified two factors within IU, namely, prospective IU and inhibitory IU. Prospective IU relates to fear and anxiety in anticipation of uncertainty, whereas inhibitory IU relates to inaction in the face of uncertainty. In a community sample, Carleton et al. (2010) found that the inhibitory aspect of IU explained unique variance in social phobia symptoms over and above positive and negative affect, fear of negative evaluation, and anxiety sensitivity. McEvoy and Mahoney (2011a) also found that the inhibitory component of IU explained unique variance in social phobia symptoms while controlling for neuroticism and symptoms of other internalizing disorders (GAD, OCD, panic disorder, agoraphobia, and depression). McEvoy and Mahoney (2011b) further demonstrated that inhibitory IU partially mediated the relationship between neuroticism and symptoms of social phobia even when controlling for symptoms of other internalizing disorders. Thus there appears to be a robust relationship between IU and social phobia symptoms. A number of studies have explored changes in IU across cognitive behavior therapy (CBT) which has been shown to be an effective treatment for anxiety disorders (Butler, Chapman, Forman, & Beck, 2006; Hofmann & Smits, 2008). If IU is associated with the maintenance of anxiety disorders, IU should reduce following treatment. Reductions in IU have been reported during treatment for GAD and OCD with studies typically finding that reductions in IU were significantly correlated with improvements in core symptoms and occurred prior to, or concurrent with, major symptom improvement (Belloch et al., 2011; Dugas & Ladouceur, 2000; Goldman, Dugas, Sexton, & Gervais, 2007; Ladouceur, Dugas, et al., 2000; Overton & Menzies, 2005). One study to date has explored IU within the context of social phobia treatment. In a single-case design series, Hewitt, Egan, and Rees (2009) found that an IU-based intervention significantly reduced social anxiety symptoms for a man with comorbid diagnoses of social phobia, panic disorder, generalized anxiety disorder, major depressive disorder, and dysthymia. IU also reduced following treatment, but the single-case design limits conclusions about (a) the relationship between improvements in IU and reductions in social phobia symptoms, and (b) the generalizability of these relationships. Further study is needed to replicate and extend these findings by examining associations between changes in social anxiety and IU following CBT with larger clinical samples. Research is also needed to explore changes in IU specifically associated with social situations. As Carleton et al. (2010) have
speculated, the degree to which people with social phobia can tolerate uncertainty associated with social situations may affect their level of social anxiety. Moreover, the predictive utility of IU in relation to CBT outcomes for social phobia is yet to be examined. Investigating the relationship between IU and comorbid depression is another avenue for additional research given the high prevalence of depression in people with social phobia (Mineka, Watson, & Clark, 1998). The first aim of this study was to examine changes in IU, social anxiety, and depression during cognitive behavior therapy, as well as to explore the relationships between these variables. The second aim was to examine the predictive utility of IU with respect to changes in social phobia symptoms following treatment. The first hypothesis is that CBT will lead to significant reductions in symptoms of social phobia, depression, and IU. Consistent with previous research (Carleton et al., 2010; McEvoy & Mahoney, 2011a), the second hypothesis is that reductions in IU will correlate significantly with reductions in social phobia and depression symptoms. The third hypothesis is that changes in IU will significantly predict post-treatment social phobia symptoms after controlling for pretreatment social phobia symptoms and changes in depression during treatment. 2. Method 2.1. Participants Participants (N ¼ 32, 50% male) were adults with social phobia who completed a cognitive behavior group therapy (CBGT) program at a specialist anxiety disorders treatment service. The mean age of participants was 31.41 years (SD ¼ 9.97) and 88% had completed high school. In terms of relationship status, 16% reported that they were married or in de facto relationships, 75% were never married, and 9% separated or divorced. Participants were recruited from 10 group programs each containing five to eight participants. On average, participants attended 6.81 (SD ¼ .40) sessions of the total seven. Prior to treatment, participants were administered the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994). All participants met criteria for a diagnosis of social phobia and reported that it was their principal area of concern. Additional diagnoses included GAD (34%), major depressive disorder (28%), dysthymic disorder (34%), specific phobia (25%), panic disorder with or without agoraphobia (6%), OCD (3%), alcohol use disorder (9%), and drug use disorder (3%). The mean number of diagnoses was 2.56 (SD ¼ 1.32) with 16% meeting criteria for two diagnoses, 41% reporting three diagnoses, and 16% with four or more diagnoses. 2.2. Measures 2.2.1. Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) ADIS-IV (Brown et al., 1994) is a structured diagnostic interview for the anxiety, mood, somatoform, and substance use disorders. Diagnoses are made according to the criteria described in the Diagnostic and Statistical Manual (DSM-IV; American Psychiatric Association, 1994). Brown, DiNardo, Lehman, and Campbell (2001) provide evidence of good inter-rater reliability for the principal diagnosis of social phobia (k ¼ .77). Inter-rater reliability for the additional disorders sampled in the current study is acceptable (k ¼ .63e.95, Brown et al., 2001). Evidence of construct validity, including discriminant and convergent validity, has been demonstrated (Brown, Chorpita, & Barlow, 1998). In the current study, diagnosticians were four clinical psychologists and three psychiatric registrars. Training involved (a)
A.E.J. Mahoney, P.M. McEvoy / J. Behav. Ther. & Exp. Psychiat. 43 (2012) 849e854
thorough reading of the ADIS-IV protocol, (b) observation of an experienced interviewer conducting an ADIS-IV, and (c) administration of an ADIS-IV while being observed by an experienced interviewer. After the training interviews, diagnosticians compared and reviewed diagnoses. All clinicians had extensive experience in the assessment and treatment of internalizing disorders. Principal diagnoses of social phobia were determined collaboratively by asking clinicians and participants to choose which disorder was the most distressing and life-interfering disorder at the time of interview. 2.2.2. Intolerance of Uncertainty Scale- Situation-Specific Version (IUS-SS) The 12-item IUS-SS (Mahoney & McEvoy, 2011b) is an adaptation of the IUS-12 (Carleton et al., 2007) and was used to assess IU associated with social and performance situations. To complete the IU-SS, participants first described a social or performance situation that regularly occurred and was distressing for them. Typical situations described included public speaking, talking to people, and meetings at work. Items relating to IU were then completed in reference to that situation (e.g., ‘I can’t stand being taken by surprise in this situation’ or ‘The smallest doubt can stop me from acting in this situation’). The situation described by participants at pre-treatment was inserted into the questionnaire at posttreatment. Items are rated along a 5 point scale from Not at all characteristic of me to Entirely characteristic of me. The measure has a unitary factor structure and excellent internal consistency (a ¼ .94, average inter-item correlation ¼ .55, Mahoney & McEvoy, 2011b). Evidence of convergent and divergent validity has been demonstrated via expected relationships with measures of personality dimensions, alcohol use, and symptoms of anxiety and depressive disorders (Mahoney & McEvoy, 2011b). Internal consistency at pre-treatment in this study was high (a ¼ .93). 2.2.3. Social Interaction Phobia Scale (SIPS) The SIPS (Carleton et al., 2009) is a 14-item measure of social phobia symptoms, specifically social interaction anxiety, fear of overt evaluation, and fear of attracting attention. The SIPS items were derived from factor analyses of the Social Phobia Scale and Social Interaction Anxiety Scale (Mattick & Clarke, 1998). Internal consistency in clinical and undergraduate samples is high (a ¼ .92), and evidence of factorial stability, convergent validity, and discriminant validity has been provided (Carleton et al., 2009). In this study, the total score was employed rather than subscale scores in order to be consistent with previous research (Carleton et al., 2010). In the current sample, internal reliability was high (a ¼ .90). 2.2.4. Beck Depression Inventory (BDI-II) The BDI-II (Beck, Steer, & Brown, 1996) is a 21-item measure of depression symptoms experienced during the previous fortnight. Internal consistency (a ¼ .92) and testeretest reliability (r ¼ .93 over 1 week) are established (Beck et al., 1996), and evidence of construct validity has been demonstrated (e.g. Dozois, Dobson, & Ahnberg, 1998; Osman, Kopper, Barrios, Gutierrez, & Bagge, 2004). Steer, Ball, Ranieri, and Beck (1997) also provide evidence of convergent validity, while Osman et al. (1997) found support for the discriminant validity of the BDI-II. The BDI-II has also been shown to be sensitive to change during CBGT treatment for social phobia (McEvoy, 2007). In this study internal reliability was high (a ¼ .95). 2.3. Procedure Participants were referred to a specialist anxiety disorders treatment service. Participants completed the ADIS-IV (Brown
851
et al., 1994) during which social phobia was identified, collaboratively between patient and doctor, as the most distressing and lifeinterfering current difficulty. Participants then completed a 7-week CBGT program and were administered measures of IU, social anxiety, and depression at pre- and post-treatment. The 7-week CBGT has been shown to be effective and is described in detail elsewhere (McEvoy, 2007). Treatment comprised seven 4-hour sessions conducted weekly. All sessions were highly structured and manualized to ensure treatment integrity. Treatment groups were lead by four masters and doctoral level clinical psychologists experienced in the treatment of social phobia and the treatment protocol. In brief, treatment involved (a) psycho-education regarding the nature of social phobia and its cognitive behavioral maintaining factors, (b) development of personalized formulations consistent with cognitive models of social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997), (c) cognitive restructuring, (d) graded exposure and behavioral experiments, (e) reduction of safety-seeking behaviors, (f) video feedback, (g) encouragement to shift attention onto the task at hand when anxious, and (h) application of treatment principles (e.g., thought challenging, attention focusing, behavioral experiments) to repetitive negative thinking (i.e., worry, rumination, post-event processing) and associated meta-beliefs. Learning to tolerate uncertainty before, during, and after social situations was emphasized during treatment and integrated into core skills (e.g., behavioral experiments were conceptualized as tests firstly to examine if feared outcomes occurred, and secondly to learn to tolerate not fully knowing if one were judged negatively or not). 3. Results 3.1. Changes in social anxiety, depression, and IU following treatment Table 1 provides pre- and post-treatment means for the SIPS, BDI-II, and IUS-SS. Pre-treatment means for the SIPS placed participants in the clinical range (Carleton et al., 2009), while pretreatment BDI-II scores fell within the moderate range for depression (Beck et al., 1996). Pre-treatment IU scores were similar to those previously found in clinical samples (Mahoney & McEvoy, 2011a). All measures demonstrated acceptable levels of skewness (j.53j) and kurtosis (j.95j). Repeated measures ANOVAs revealed significant differences from pre- to post-treatment for the SIPS, F(1, 31) ¼ 48.35, p < .001, BDI-II, F(1, 31) ¼ 18.53, p < .001, as well as the IUS-SS, F(1, 31) ¼ 41.18, p < .001. Effect sizes (r2) are given in Table 1. Effect sizes were in the large range for the SIPS and IUS-SS and in the moderate to large range for the BDI-II. 3.2. Relationships between IU, social phobia, and depression Bivariate Pearson correlation coefficients were calculated to determine the associations between IU and symptoms of social Table 1 Means, standard deviations, and effect sizes of outcome measures pre- and posttreatment. Outcome measures
SIPS BDI-II IUS-SS
Pre-treatment
Post-treatment
M
SD
M
SD
34.63 19.10 38.94
10.98 14.15 12.39
23.59 10.35 28.34
11.84 9.46 12.30
Effect size .61 .37 .57
Note. M ¼ mean, SD ¼ standard deviation, SIPS ¼ Social Interaction Phobia Scale, BDI-II ¼ Beck Depression Inventory, IUS-SS ¼ Intolerance to Uncertainty ScaleSituation-specific version. Effect size ¼ r2.
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anxiety and depression at pre-treatment. The SIPS and BDI-II correlated significantly with the IUS-SS, r ¼ .49, p ¼ .004 and r ¼ .56, p ¼ .001 respectively, and with each other, r ¼ .71, p < .001. For pre-treatment measures, a partial correlation between the SIPS and the IUS-SS was calculated controlling for depression scores. The SIPS did not correlate with IU when depression was controlled for, Part r ¼ .17, p ¼ .37. A partial correlation also showed that the association between pre-treatment depression scores and IU just fell short of statistical significance when controlling for pretreatment SIPS, Part r ¼ .34, p ¼ .06. Change scores from pre- to post-treatment were computed for the SIPS, BDI-II, and IUS-SS. Bivariate Pearson correlation coefficients were calculated to determine the associations between IU and symptom measures. Reductions in the IUS-SS were significantly positively correlated with reductions in the SIPS, r ¼ .57, p ¼ .001. In contrast, reductions in depression symptoms did not significantly correlate with changes in the IUS-SS, r ¼ .24, p ¼ .20. A partial correlation between changes in the SIPS and the IUS-SS was calculated controlling for the change in depression scores. The correlation continued to be significant and positive, Part r ¼ .54, p ¼ .002. 3.3. Regression analyses predicting post-treatment outcomes A hierarchical regression was conducted to determine if reductions in IU predicted post-treatment social phobia symptoms after taking into account pre-treatment social phobia symptoms and changes in depression symptoms. The criterion variable was posttreatment SIPS score. Pre-treatment SIPS score was entered at Step 1, while changes in the BDI-II were entered at Step 2. At Step 3, changes in the IUS-SS pre- to post-treatment were entered. As seen in Table 2, pre-treatment SIPS score and changes in depression were significant predictors of post-treatment scores at each step in which they were entered. At Step 3, changes in intolerance of uncertainty in relation to social situations emerged as a significant predictor of SIPS at post-treatment. 4. Discussion Intolerance of uncertainty has been most heavily implicated in the development and maintenance of excessive worry and generalized anxiety disorder; however, recent research has supported the transdiagnostic conceptualization of IU and suggests that IU contributes to a range of symptoms across the anxiety and depressive disorders (Gentes & Ruscio, 2011; McEvoy & Mahoney, 2011a). This study sought to examine the relationship between IU and social phobia symptoms during cognitive behavior group therapy. Our first hypothesis was that the group treatment would lead to significant reductions in symptoms of social phobia and depression, as well as decrease IU associated with social situations. This hypothesis was fully supported; the effect sizes for reductions in IU, social anxiety symptoms, and depression symptoms were in the
moderate to large range. These results are consistent with previous research supporting the effectiveness of CBGT for social phobia (McEvoy, 2007), as well as findings which demonstrate that IU reduces during cognitive behavior therapy for anxiety disorders such as GAD and OCD (Belloch et al., 2011; Dugas & Ladouceur, 2000; Goldman et al., 2007; Ladouceur, Dugas, et al., 2000; Overton & Menzies, 2005). Our treatment outcomes also appear consistent with those reported in Hewitt et al.’s (2009) single-case study that found that an IU-based CBT intervention led to clinically significant reductions in IU and social phobia symptoms. The primary focus of the intervention in the Hewitt et al. study was to reduce IU via cognitive and behavioral strategies. This study found that incorporating IU-based interventions into an existing CBGT protocol (McEvoy, 2007) also led to significant reductions in social anxiety symptoms and IU. Like previous research (Mahoney & McEvoy, 2011b), we found that symptoms of social anxiety and depression were significantly associated with IU at pre-treatment, but the association between IU and social anxiety symptoms did not remain significant when controlling for comorbid depression. This was also the case for the association between depression symptoms and IU when controlling for social anxiety. These findings suggest that social anxiety and depression symptoms were generally associated with common variance in IU. In contrast, McEvoy and Mahoney (2011a) have previously found that IU explains unique variance in symptoms of social anxiety and depression after controlling for comorbid symptoms. However, McEvoy and Mahoney employed a large (N ¼ 463) mixed clinical sample and a trait measure of IU (rather than IU associated specifically with social anxiety situations) and, as such, may have better placed to detect relationships between IU and symptoms of various internalizing disorders. The hypothesis that reductions in IU would correlate significantly with reductions in social phobia and depression symptoms was partially supported. Although reductions in IU were associated with reductions in social anxiety symptoms, the relationship between changes in IU and depression symptoms was not significant. This suggests that increasing tolerance of uncertainty in social situations is related to reducing social anxiety symptoms, but not depression symptoms. It is possible that the relationship between depression and IU may have been obscured in this study because IU was assessed with specific reference to social situations, treatment did not target IU in relation to depressogenic symptoms and situations, and the sample was selected based on a principal diagnosis of social phobia. This study was the first to examine the relationships between changes in depression and IU across treatment, whereas previous studies have tended to assess the relationship between IU and depression symptoms at a single time point (e.g., Gentes & Ruscio, 2011; McEvoy & Mahoney, 2011a). More longitudinal and experimental studies are needed to examine the relationship between IU and depression symptoms when depression is either the primary or comorbid clinical concern, and when IU is assessed with reference to depressogenic situations.
Table 2 Summary of hierarchical linear regression predicting post-treatment social phobia symptoms. Criterion
Predictors
DR2
B
SEB
Beta
t
Part r
SIPS post-treatment
Step 1: SIPS pre-treatment Step 2: SIPS pre-treatment BDI-II D Step 3: SIPS pre-treatment BDI-II D IUS-SS D
.48*** .09*
.75 .93 .36 .93 .27 .47
.14 .15 .14 .13 .12 .14
.69 .86 .35 .86 .27 .37
5.27*** 6.23*** 2.53* 7.30*** 2.19* 3.45**
.69 .76 .31 .75 .23 .36
.13**
Note. SIPS ¼ Social Interaction Phobia Scale, BDI-II ¼ Beck Depression Inventory, IUS-SS ¼ Intolerance to Uncertainty Scale- Situation-specific version, ***p < .001 **p < .01 *p < .05.
A.E.J. Mahoney, P.M. McEvoy / J. Behav. Ther. & Exp. Psychiat. 43 (2012) 849e854
Depression symptoms did reduce following treatment and were predictive of post-treatment social anxiety symptoms after taking pre-treatment social anxiety into account. Specifically, greater reductions in depression were associated with lower social anxiety symptoms at post-treatment. However, given the lack of association between changes in IU and depression, it seems unlikely that IUbased processes were responsible for the improvement in depression symptoms. Treatments which target specific disorders (e.g., social phobia) have previously been shown to lead to significant reductions in comorbid symptoms (e.g., symptoms of generalized anxiety disorder and depression, Titov, Gibson, Andrews, & McEvoy, 2009). One reason for this may be that diagnosis-specific treatments remediate underlying maladaptive processes or vulnerabilities that are common or shared across a variety of disorders (such as repetitive negative thinking, IU, neuroticism, or avoidance). Our findings suggest this shared maladaptive process may not be IU in the case of secondary depression reducing during social phobia treatment. Previous research has found that changes in metacognitive beliefs, another shared or transdiagnostic construct, were associated with reductions in depression following CBGT for social phobia (McEvoy, Mahoney, Perini, & Kingsep, 2009). It is also possible that depression symptoms reduced because as social anxiety symptoms improved patients became more behaviorally activated and optimistic about the future. Further research elucidating the mechanisms that drive improvement in primary and secondary symptoms during cognitive behavior therapy will have important implications for transdiagnostic theories and treatments. Our third hypothesis was that changes in IU would predict post-treatment social phobia symptoms after controlling for pre-treatment social phobia symptoms and changes in depression following treatment. This hypothesis was fully supported; greater reductions IU were associated with lower post-treatment social phobia symptoms. These findings suggest that enhancing tolerance of uncertainty associated with social situations may reduce symptoms of social phobia. Cognitive interventions may address IU beliefs such as ‘Uncertainty in this [social] situation keeps me from living a full life’, whereas behavioral strategies could reduce avoidance via behavioral experiments and graded exposure to uncertain situations (e.g., spontaneous conversations, impromptu speeches, or exposure to ambiguous social cues such as being ignored). It must be noted that the correlational nature of this study precludes conclusions about the direction or causal nature of the relationship between IU and social anxiety symptoms. However, we are encouraged to consider a causal relationship between IU and social anxiety symptoms because previous experimental research has demonstrated that inducing IU leads to increased worry (Ladouceur, Gosselin, et al., 2000), and while excessive worry is the core diagnostic feature of GAD, it is also evident in social phobia and other anxiety disorders (Brown, Antony, & Barlow, 1992). Nevertheless, potential causal relationships need to be established via experimental research involving social phobia symptoms in particular. The present findings should be interpreted within the context of several limitations. Current cognitive models of social phobia (Clark & Wells, 1995; Rapee & Heimberg, 1997) emphasize constructs such as fear of negative evaluation, avoidance, safety-behaviors, selffocused attention, the observer perspective, and post-event processing in the maintenance of social phobia. These variables were not assessed in the current study, and as such we are unable to examine the relative importance of IU in determining changes in social phobia symptoms after therapy. Although Boelen and Reijntjes (2009) found that IU predicted social anxiety symptoms over and above neuroticism, fear of negative evaluation, and other variables in a non-clinical sample, future research is needed to investigate how changes in IU relate to symptom improvement in clinical samples while controlling for established maintaining
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factors. This would allow us to understand the comparative importance of IU to the maintenance of social phobia in contemporary cognitive models and treatments. Additionally, no reliability data were available for ADIS diagnoses, although mean scores on measures of social anxiety and depression symptoms in the current sample fell within clinical ranges. This study also lacked follow-up data which prevented us from examining the stability of IU changes over time and exploring longitudinal relationships between IU and symptoms. This study is the first to investigate changes in IU across CBGT for social phobia and to examine relationships between changes in IU and symptoms of social phobia and depression. IU and symptoms of social anxiety and depression all reduced following treatment. Reductions in IU were predictive of post-treatment social phobia symptoms after controlling for pre-treatment social phobia symptoms and changes in depression. These findings suggest that enhancing tolerance of uncertainty may play a role in the optimal management of social phobia. Declaration of interest Neither author has any conflict of interest to declare. Authors were funded by their salaries from their current places of employment; funding sources had no involvement in the study design, data collection, analysis or interpretation, or manuscript preparation. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II Manual. New York: Harcourt Brace Janovich. Belloch, A., Cabedo, E., Carrio, C., Fernandez-Alvarez, H., Garcia, F., & Larsson, C. (2011). Group verses individual cognitive treatment for obsessive-compulsive disorder: changes in non-OCD symptoms and cognitions at post-treatment and one-year follow-up. Psychiatry Research, 187, 174e179. Boelen, P. A., & Reijntjes, A. (2009). Intolerance of uncertainty and social anxiety. Journal of Anxiety Disorders, 29, 130e135. Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30, 33e37. Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology, 107, 179e192. Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule for DSM-IV. Albany, NY: Graywind Publications. Brown, T. A., Dinardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: implications for classification of emotional disorders. Journal of Abnormal Psychology, 110, 49e58. Buhr, K., & Dugas, M. J. (2002). The Intolerance of Uncertainty Scale: psychometric properties of the English version. Behaviour Research and Therapy, 40, 931e945. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive behaviour therapy: a review of meta-analyses. Clinical Psychology Review, 26, 17e31. Carleton, R. N., Collimore, K. C., & Asmundson, G. (2010). “It’s not just the judgments e It’s that I don’t know”: intolerance of uncertainty as a predictor of social anxiety. Journal of Anxiety Disorders, 24, 189e195. Carleton, R. N., Collimore, K. C., Asmundson, G. J. G., McCabe, R., Rowa, K., & Antony, M. M. (2009). Refining and validating the Social Interaction Anxiety Scale and the Social Phobia Scale. Depression and Anxiety, 26, E71eE81. Carleton, R. N., Norton, P. J., & Asmundson, G. (2007). Fearing the unknown: a short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105e117. Carleton, R. N., Weeks, J. W., Howell, A. N., Asmundson, G. J. G., Antony, M. M., & McCabe, R. E. (2011). Assessing the latent structure of the intolerance of uncertainty construct: an initial taxometric analysis. Journal of Anxiety Disorders, doi:10.1016/j.janxdis.2011.10.006. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, & M. R. Liebowitz (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69e93). New York: Guildford Press. Dozois, D. J. A., Dobson, K. S., & Ahnberg, J. L. (1998). A psychometric evaluation of the Beck Depression Inventory-II. Psychological Assessment, 10, 83e89.
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