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Journal of Anxiety Disorders 26 (2012) 468479

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Journal of Anxiety Disorders

Increasingly certain about uncertainty: Intolerance of uncertainty across anxiety and depression
R. Nicholas Carleton a, , Myriah K. Mulvogue a , Michel A. Thibodeau a , Randi E. McCabe b , Martin M. Antony c , Gordon J.G. Asmundson a
a b c

Department of Psychology, University of Regina, Regina, SK, Canada Department of Psychiatry and Behavioural Neurosciences, McMaster University and Anxiety Treatment and Research Centre, St. Josephs Healthcare Hamilton, ON, Canada Department of Psychology, Ryerson University, Canada

a r t i c l e

i n f o

a b s t r a c t
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, obsessivecompulsive 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 signicant difference in IUS-12 scores across diagnostic groups in the clinical sample; specically, people with social anxiety disorder reported higher scores (p < .01; 2 = .03) than people with panic disorder. People diagnosed with an anxiety disorder or depression reported signicantly 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 at distribution of IU. Response patterns were invariant across diagnostic groups as demonstrated by multi-group conrmatory factor analyses, but varied between clinical and nonclinical samples. Overall, the ndings 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 ndings, implications, and future research directions are discussed. 2012 Published by Elsevier Ltd.

Article history: Received 17 September 2011 Received in revised form 23 January 2012 Accepted 27 January 2012 Keywords: Intolerance of uncertainty IUS-12 Anxiety disorders Depression Diagnostic differentiation Normative Psychometric properties

Current perspectives for psychological treatment (Brown & Barlow, 2009; Norton & Philipp, 2008) posit that the etiological and neurobiological parallels, as well as considerable diagnostic comorbidity, render anxiety and mood disorders more alike than unalike (Wilamowska et al., 2010). Such disorders have been historically categorized and conceptualized as discrete pathologies; however, increasing evidence implicates common underlying constructs (Carleton, Abrams, Asmundson, Antony, & McCabe, 2009; Confer et al., 2010; McEvoy & Mahoney, 2011; Norton & Mehta, 2007; Starcevic & Berle, 2006; Taylor, 1993). Identifying and understanding constructs common to anxiety disorders and depression may provide directions for investigating potential transdiagnostic

Corresponding author at: Department of Psychology, University of Regina, Regina, Saskatchewan, S4S 0A2, Canada. Tel.: +1 306 337 2473; fax: +1 306 585 4854. E-mail addresses: carletor@uregina.ca, Nick.Carleton@uregina.ca (R.N. Carleton). 0887-6185/$ see front matter 2012 Published by Elsevier Ltd. doi:10.1016/j.janxdis.2012.01.011

vulnerabilities to fear-related distress, and provide further rationale for developing transdiagnostic treatment protocols. Anxiety is believed to require a sense of uncontrollability focused on the possibility of future threat, danger, or other potentially negative events (Surez, Bennett, Goldstein, & Barlow, 2009, p. 153). Accordingly, there appears to be implicit theoretical support for the notion that negative reactions to uncertainty, known as intolerance of uncertainty (IU), may be an intrinsic construct for all anxiety disorders (Asmundson & Carleton, 2005; Carleton, Norton, & Asmundson, 2007; Carleton, Sharpe, & Asmundson, 2007; Holaway, Heimberg, & Coles, 2006). As such, examining IU as a potentially transdiagnostic construct appears well-warranted. There has been considerable discussion regarding the denition of IU (Starcevic & Berle, 2006). The construct has been broadly conceptualized as a negative response to ambiguity (Freeston, Rhaume, Letarte, Dugas, & Ladouceur, 1994) and narrowly as the tendency for an individual to consider the possibility of a negative event occurring as unacceptable and threatening irrespective of the

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R.N. Carleton et al. / Journal of Anxiety Disorders 26 (2012) 468479 469

probability of its occurrence (Carleton, Sharpe, et al., 2007; Dugas, Gosselin, & Landouceur, 2001). IU may involve a negative reaction to uncertainty as well as beliefs about the inability to cope with ambiguity and change (Holaway et al., 2006; Obsessive Compulsive Cognitions Working Group, 1997); moreover, uncertainty itself can be considered threatening (Epstein, 1972), promoting or maintaining anxiety, and exacerbating the perception of threat (Dugas, Hedayati, et al., 2005; Dugas, Marchand, & Ladouceur, 2005; Hock & Krohne, 2004). The most recent denition describes IU as a dispositional characteristic resulting from negative beliefs about uncertainty and its implications (Dugas & Robichaud, 2007). Available research suggests that IU is future-oriented, therein differing from the more present-oriented construct described as intolerance of ambiguity (Grenier, Barrette, & Ladouceur, 2005). There is increasingly robust evidence that IU can be represented as having two dimensions prospective IU (i.e., the cognitively focused dimension of IU; e.g., Unforeseen events upset me greatly) and inhibitory IU (i.e., the behaviourally focused dimension of IU; e.g., The smallest doubt can stop me from acting). Each of the dimensions as represented by the respective factors has been associated with different anxiety disorder symptoms (McEvoy & Mahoney, 2011). Specically, the prospective IU subscale was expected to be more related to worry and obsessive compulsive symptoms, whereas the inhibitory IU subscale was expected to be more related to social anxiety, panic, agoraphobia, and depression. There is growing evidence that IU is ubiquitous. Researchers have explored IU in large undergraduate (Berenbaum, Bredemeier, & Thompson, 2008; Norton, 2005), community (Sexton & Dugas, 2009), and clinical populations (Dugas et al., 2007; McEvoy & Mahoney, 2011; Tolin, Abramowitz, Brigidi, & Foa, 2003), demonstrating a range of scores, substantial construct variability, and a generally normal distribution. In clinical populations, IU has been most thoroughly investigated in generalized anxiety disorder (GAD). Relative to people with a range of other anxiety disorders, those with GAD have historically reported higher scores on IU (Ladouceur et al., 1999). An initial comparison was made using small clinical samples comparing persons with a principal diagnosis of GAD (n = 24), an additional diagnosis of GAD (n = 24), other anxiety disorders (n = 38), and a nonclinical group (n = 20). The results indicated signicantly higher levels of IU as measured by the Intolerance of Uncertainty Scale (IUS; Freeston et al., 1994) for those with a principal or additional diagnosis of GAD relative to individuals with other anxiety disorders, and all clinical participants reported higher IU than did nonclinical controls (Ladouceur et al., 1999). In a similar study comparing IUS scores across small samples of individuals with GAD (n = 17) and panic disorder (n = 28), the GAD group reported higher scores (Dugas, Hedayati, et al., 2005; Dugas, Marchand, et al., 2005). Similarly, theorists have suggested IU as a broad specier for worry, the hallmark symptom of GAD, which is a cognitive strategy used in attempts to control the unknown (Dugas, Buhr, & Ladouceur, 2004; Ladouceur, Gosselin, & Dugas, 2000). Indeed, IU is a robust predictor of worry (Buhr & Dugas, 2006) and people with high IU have been shown to worry more when anxious than not (Buhr & Dugas, 2009). Contrasting earlier notions that heightened IU distinguishes GAD from other anxiety disorders (Dugas, Marchand, et al., 2005; Ladouceur et al., 1999; Sexton, Norton, Walker, & Norton, 2003), researchers have identied important relationships between IU and other anxiety disorders using regression-based analyses in undergraduate and clinical samples (Gentes & Ruscio, 2011; Norton & Mehta, 2007; Norton, Sexton, Walker, & Norton, 2005). A recent meta-analysis found no support for the hypothesis that IU may be specic only to GAD (Gentes & Ruscio, 2011); instead, the authors suggested that ndings indicating IU differentiates GAD from other disorders may have been inuenced by the GAD-specic content

assessed by the original IUS. Indeed, elevated IU has been associated with OCD at levels comparable to GAD (Holaway et al., 2006), particularly for those people focused on checking (Lind & Boschen, 2009; Tolin et al., 2003). IU has also accounted for variance in social anxiety in comparable degree to the hallmark fear of negative evaluation typically associated with SAD (Boelen & Reijntjes, 2009; Carleton, Collimore, & Asmundson, 2010; Norton et al., 2005; van der Heiden et al., 2010). A similar relationship has been found between IU and panic disorder, being comparable in degree to the relationship between panic disorder and anxiety sensitivity (Buhr & Dugas, 2009; Carleton, Sharpe, et al., 2007). There is also substantial evidence of an association between IU and depression (Boelen, Vrinssen, & van Tulder, 2010; Butzer & Kuiper, 2006; Miranda, Fontes, & Marroquin, 2008; Norton & Mehta, 2007; Norton et al., 2005; van der Heiden et al., 2010; Yook, Kim, Suh, & Lee, 2010), with some researchers nding evidence that IU may be more strongly associated with depression symptoms than with GAD symptoms (Miranda et al., 2008). There have been indirect comparisons of IU endorsement rates (i.e., the aggregated Likert-scale item scores within a self-report measure of IU) across disorders made by assessing relative contributions of IU to different diagnostic symptoms (Gentes & Ruscio, 2011; Norton & Mehta, 2007; Norton et al., 2005; Sexton et al., 2003); moreover, levels of IU have been compared in nonclinical samples (Carleton, Sharpe, et al., 2007), between two disorders (Dugas, Marchand, et al., 2005), and between GAD and a range of other disorders (McEvoy & Mahoney, 2011). Other studies have provided further evidence that IU predicts several types of symptoms beyond neuroticism (Boelen & Reijntjes, 2009), anxiety sensitivity (Boelen & Reijntjes, 2009; Dugas et al., 2001), fear of anxiety (Buhr & Dugas, 2009), metabeliefs (de Bruin, Rassin, & Muris, 2007; Dugas et al., 2007), and positive and negative affectivity (Carleton, Collimore, et al., 2010), providing increasingly robust evidence for the broad and important inuence of IU in psychopathology. The aforementioned evidence suggests that IU is important for anxiety and depression symptoms. Nevertheless, the current study represents the rst attempt at systematically examining IU endorsement rates and response patterns (i.e., the relative endorsement rates of different Likert-scale items within a self-report measure of IU) across undergraduate, community, and clinical samples with a variety of relevant anxiety disorders and depression. Such a study is necessary to consolidate IU as ubiquitous, demonstrate the relative increase in persons with psychopathology, and support investigating it as a potentially important transdiagnostic construct for the development and maintenance of anxiety and mood disorders (Carleton, Sharpe, et al., 2007; McEvoy & Mahoney, 2011). The primary purpose of the present study was to investigate the endorsement rates and response patterns of IU as well as differences in these rates and patterns across individuals with various principal anxiety disorder diagnoses or depression relative to undergraduate and community samples. Establishing the presence or absence of differential endorsement patterns represents an important step towards evaluating IU as a transdiagnostic cognitive vulnerability factor (Garber & Hollon, 1991; Ingram, 2003). Based on the previous research, IU endorsement was expected to be higher in the clinical sample relative to both the undergraduate and community samples; however, endorsement was expected to be even higher for persons with a principal diagnosis of GAD or OCD relative to persons with other principal diagnoses (Dugas, Marchand, et al., 2005; Ladouceur et al., 1999; Sexton et al., 2003). In line with previous research (Carleton, Sharpe, et al., 2007; Khawaja & Yu, 2010; Sexton & Dugas, 2009), a 2-factor solution was expected for the IUS-12, comprising prospective IU and inhibitory IU. Similarly, and based on previous research (McEvoy & Mahoney, 2011), the prospective IU subscale was expected to be more related to worry and obsessive compulsive symptoms, whereas the inhibitory

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470 Table 1 Rates of comorbid diagnoses. Principal diagnosis Additional diagnosis None MDD PDA GAD SAD OCD 8% 22% 13% 17% 18% MDD 29% 24% 32% 32% PDA 23% 14% 13% 12% GAD 19% 12% 21% 12% SAD 38% 15% 27% 13% OCD 4% 4% 10% 6% Other Axis I 8% 8% 13% 13% 13% R.N. Carleton et al. / Journal of Anxiety Disorders 26 (2012) 468479

Notes: MDD, major depressive disorder; PDA, panic disorder with or without agoraphobia; GAD, generalized anxiety disorder; SAD, social anxiety disorder; OCD, obsessivecompulsive disorder.

IU subscale was expected to be more related to social anxiety, panic, agoraphobia, and depression. Given such precedent differences associated with the dimensions of IU, assessing for such differences in the current study appears well warranted. 1. Method 1.1. Participants The primary participants for this study included patients (n = 376; 146 men [Mage = 36.55; SD = 13.58] and 230 women [Mage = 35.09; SD = 11.81]) from an established outpatient anxiety treatment and research center. Participants received a principal Axis I diagnosis based upon the disorder that was found to be most disabling at the time of the assessment, including SAD (n = 120; 32%), panic disorder with or without agoraphobia (PDA; n = 89; 24%), GAD (n = 63; 17%), OCD (n = 60; 16%), or major depressive disorder (MDD; n = 26; 7%). The most common additional diagnoses included MDD and SAD (Table 1). There were insufcient numbers of people reporting specic phobia (n = 11) or anxiety disorder not otherwise specied (ADNOS; n = 7) as their principal diagnosis to include those two groups. In addition, posttraumatic stress disorder (PTSD) was not included as it is not a disorder treated at the treatment center. Diagnostic criteria were based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; DSM-IV-TR; American Psychiatric Association, 2000), and diagnoses were assigned using the Structured Clinical Interview for DSM-IV (SCID-I; First, Spitzer, Gibbon, & Williams, 1996). Most participants completed at least some postsecondary education (69%), graduated from high school (17%), or completed some high school but did not graduate (12%). The majority described themselves as Caucasian (94%), Asian (3%), or Aboriginal (2%), and as either single (45%), married/cohabitating (46%), or divorced (8%). Additional participants were included from undergraduate and community samples who completed the demographic questionnaire as well as a measure of IU as part of larger, ongoing investigations. The two convenience samples were included to contextualize IU responding by the clinical participants relative to what can be presumed to be generally nonclinical samples. In addition, the data from these two samples further expand the normative IU data available in the literature. The rst normative sample included undergraduates (n = 428; 103 men [Mage = 20.58; SD = 3.04] and 325 women [Mage = 20.47; SD = 3.86]) who completed measures as part of other investigations approved by the University of Regina Research Ethics Board. Participants identied their ethnicity as Caucasian (87%), Aboriginal (2%), Asian (7%), or other (4%). Most reported being single (82%), married or cohabitating (12%), separated or divorced (1%), or chose not to answer (5%). Undergraduates were recruited via campus advertisements directing them to a secure website for completion of an online questionnaire package. The second normative sample included community members (n = 571) from across Canada (187 men [Mage = 27.86; SD = 10.37]

and 384 women [Mage = 28.72; SD = 10.81]) who completed the measures as part of other web-based investigations approved by the University of Regina Research Ethics Board. Participants were solicited with web advertising requests to participate in an online study of variables associated with anxiety. Most (67%) reported having at least some postsecondary education or completing Grade 12 (21%). The sample identied as being single (55%), married or cohabitating (34%), separated or divorced (9%), or chose not to answer (2%). Most participants identied their ethnicity as Caucasian (84%), Aboriginal (3%), Asian (5%), or other (8%). 1.2. Measures Intolerance of uncertainty scale, short form (IUS-12; Carleton, Norton, et al., 2007; Carleton, Sharpe, et al., 2007). The IUS-12 is a 12-item short-form of the original 27-item Intolerance of Uncertainty Scale (Freeston et al., 1994) that measures reactions to uncertainty, ambiguous situations, and the future (e.g., Unforeseen events upset me greatly). Items are scored on a 5-point Likert scale ranging from 1 (not at all characteristic of me) to 5 (entirely characteristic of me). The IUS-12 has a strong correlation with the original scale, rs = .94 to .96 (Carleton, Norton, et al., 2007; Khawaja & Yu, 2010), and has been shown to have two factors, prospective anxiety (7 items; e.g., I cant stand being taken by surprise) and inhibitory anxiety (5 items; e.g., When its time to act, uncertainty paralyses me), both with identically high internal consistencies, = .85 (Carleton, Norton, et al., 2007). The IUS-12 has excellent internal consistency and convergent validity with the original (Carleton, Norton, et al., 2007; Carleton, Sharpe, et al., 2007). The psychometric properties of the IUS-12 have all been replicated and reied in clinical and nonclinical samples (Carleton, Sharpe, et al., 2007; Khawaja & Yu, 2010; McEvoy & Mahoney, 2011). The IUS-12 was selected to measure IU because it is psychometrically comparable to, but briefer than, the original IUS (Khawaja & Yu, 2010) and the new symptom-focused Intolerance of Uncertainty Index (IUI; Carleton, Gosselin, & Asmundson, 2010; Gosselin et al., 2008). In addition, while the IUI was developed largely as a clinical and outcome measure, the IUS-12 has been designed specifically to research the construct in a number of different populations, across a number of different disorders. McEvoy and Mahoney (2011) have provided a compelling argument that prospective IU and inhibitory IU are more appropriate labels for the IUS-12 subscales, reecting the fact that responses have not been anxiety-specic; accordingly, the revised subscale names have been adopted herein. In addition, the subscales will be assessed separately, as well as the total score. Evidence to date has indicated differential discriminant validity associated with each subscale, such that prospective IU appears more strongly associated with GAD and OCD (i.e., anticipation of uncertainty), whereas inhibitory IU appears more strongly associated with panic disorder, SAD, and depression (i.e., uncertainty produces inhibition; Carleton, Collimore, et al., 2010; McEvoy & Mahoney, 2011).

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In the clinical sample, the internal consistency for the total score ( = .91), the prospective IU subscale score ( = .87), and the inhibitory IU subscale score ( = .86) ranged from good to excellent, and the average inter-item correlation was .47. In the undergraduate sample, the internal consistency for the total score ( = .91), the prospective IU subscale score ( = .85), and the inhibitory IU subscale score ( = .86) ranged from good to excellent, and the average inter-item correlation was .45. In the community sample, the internal consistency for the total score ( = .92), the prospective IU subscale score ( = .86), and the inhibitory IU subscale score ( = .89) ranged from good to excellent, and the average inter-item correlation was .48. Structured Clinical Interview for DSM-IV (SCID-I; First et al., 1996). The SCID-I is an established semi-structured clinical interview used to facilitate diagnosis of Axis I disorders based on DSMIV criteria. The SCID was administered only to participants from the established outpatient anxiety treatment and research center. Interviewers in the present study included psychologists, postdoctoral fellows, and predoctoral graduate students, all of whom had received extensive training and supervision in conducting this interview. All SCID-I interviews for this study were presented at a weekly team meeting chaired by a psychologist with more than 5 years of experience in training others to administer the measure. At each meeting, diagnostic questions were reviewed, and a consensus diagnosis was reached. Earlier versions of the SCID-I have been found to have adequate inter-rater reliability for all disorders (overall reliabilities range from .69 to 1.0; Zanarini & Frankenburg, 2001). 1.3. Analyses Descriptive statistics were calculated for each of the individual items and summed total and subscale scores for each of the diagnostic groups, as well as the undergraduate and community samples. Across the diagnostic groups, global assessment of function (GAF) was also assessed (American Psychiatric Association, 2000). The 100-point GAF was used to determine disorder severity rather than the 3-point SCID-I severity index because, with differentiation between ten rather than three symptom severity/impairment subcategories, and the freedom to use intermediate level ratings (e.g., 42, 75) when appropriate, the GAF offers a richer, and arguably more accurate, indication of disorder severity. Comparative analyses were performed across men and women to assess for sex differences. Empirical distributions of IUS-12 scores across diagnostic and community and undergraduate groups were studied using Kernel density estimation curves. A Kernel density estimation is a data smoothing algorithm wherein population inferences are made based on an empirical sample to draw sample distribution characteristics (Salgado-Ugarte & Perez-Hernandez, 2003). Frequency histograms effectively display relatively discrete data of one variable; however, examining and comparing multiple histograms (e.g., between groups) is difcult, and these typically do not serve as good representations of relatively continuous data (Scott, 1979). Compiled univariate Kernel density estimation curves allow a parsimonious examination of distributions across numerous groups on one variable and in one plot. A Gaussian function was used with a bandwidth of 1 to compile the curves. Visual inspection of the plot revealed how distribution features (e.g., variance, skew, kurtosis) and modality (e.g., relative normality, bimodality) differed across diagnostic groups (Salgado-Ugarte, Shimizu, & Taniuchi, 1994). There were two analyses of variance (ANOVA) conducted to compare total and subscale score means of the IUS-12 across diagnostic and undergraduate and community groups. Bootstrapping was performed to ensure the robust nature of statistically signicant results (Byrne, 2001; Davison & Hinkley, 2006; Nevitt

& Hancock, 2001). The rst ANOVA replicated and extended the ANOVA conducted by Ladouceur et al. (1999) by comparing participants with a principal diagnosis of GAD to those with (1) an additional diagnosis of GAD, (2) a principal diagnosis of any other anxiety disorder, (3) a principal diagnosis of MDD, (4) the undergraduate sample, and (5) the community sample. Tukey post hoc comparisons were conducted to assess for individual differences between group means (p < .05). Given the large number of comparisons, the alpha level was adjusted to p = .01. Additional adjustments to control for Experiment-Wise Type I error were not included to avoid the risk of a Type II error (Tabachnick & Fidell, 2007); accordingly, effect sizes were also reported and interpreted (Osborne, 2008). The second ANOVA was used to compare the total and subscale scores between each of the principal diagnostic groups (rather than collapsing diagnoses as in the rst ANOVA) as well as the undergraduate and community samples. Between-group differences were again delineated with post hoc Tukey tests. Conrmatory factor analyses (CFA) were used for three purposes: rst, to assess the t of the presumed IUS-12 2-factor structure for each of the clinical, undergraduate, and community samples; second, to assess if the IUS-12 factor structure, measurements weights (i.e., the relationship between the measured variables and their latent variables), and structural covariances (i.e., the covariances among the latent variables) differed between men and women; third, to assess if the IUS-12 factor structure, measurements weights, and structural covariances differed between each sample (i.e., clinical, undergraduate, and community) and between each diagnostic, and undergraduate, and community groups. A multiple-group CFA procedure in AMOS as described by Byrne (Byrne, 2001, 2004) was utilized to reach these purposes. Multiple group analysis in structural equation modeling allows comparisons of the same construct across samples for any identied structural equation model. AMOS allows testing of whether the groups meet an assumption of equality by examining whether different sets of path coefcients are invariant. Statistically signicant differences in measurement weights would suggest that subsequent analyses of structural covariances may not be robust; therefore, if the measurement weights differ, but the structural covariances do not, then the response patterns are similar but cannot be assumed to be entirely comparable across groups. This procedure serves as a stringent test of invariance across men and women for each of the three samples and across each of the diagnostic groups (i.e., SAD, PDA, GAD, OCD, MDD) to test for invariance based on diagnosis. The unitary model was assessed with conrmatory factor analyses using the following t indices and 90 percent condence intervals (where applicable) as representative of excellent t and values approaching these cut off scores as indicating an increasingly good t (Hu & Bentler, 1999; Tabachnick & Fidell, 2007): (1) chi-square (values should not be signicant); (2) chi-square/df ratio (values should be less than 2.0); (3) Comparative Fit Index (CFI; values must be greater than .90, and ideal ts approach or are greater than .95); (4) the Standardized Root Mean Square Residual (SRMR; values must be less than .10 and ideal ts approach or are less than .05); (5) Root Mean Square Error of Approximation (RMSEA; values must be less than .08 and ideal ts approach or are less than .05, with 90% condence interval values below .10); and (6) Expected Cross-Validation Index (ECVI); when comparing these scores across different models, lower values indicate a closer t (Browne & Cudeck, 1989, 1993). Goodness of t evaluations should emphasize the latter four t indices because of potential chi-square ination (Hu & Bentler, 1999). Multivariate normality was assessed using Mardias coefcient of multivariate kurtosis (Byrne, 2001) for all models, with results suggesting nonnormal data; however, parameter estimates and most model t indices are robust to nonnormality given maximum-likelihood estimation and a sample size of 100 or more participants (Lei &

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Lomax, 2005). Nonetheless, we used the BollenStine bootstrap chi-square and computed bootstrapped parameter estimates with estimates from a maximum-likelihood procedure, which has been demonstrated as an adequate method for resolving non-normality (Byrne, 2001; Davison & Hinkley, 2006; Nevitt & Hancock, 2001). In all cases, the statistical signicance value for the BollenStine bootstrap chi-square produced results comparable with those from the maximum-likelihood procedure for the CFA, suggesting that non-normality did not substantially impact the overall results. 2. Results 2.1. Descriptive statistics and sex comparisons Descriptive statistics are presented in Table 2. There was a higher proportion, 2 (2) = 21.56, p < .01, V = .13, of women in the undergraduate sample (76%) relative to the clinical sample (61%) and the community sample (67%). There were no differences in age between the diagnostic groups, F(4, 351) = 2.24, p > .05, eta2 = .03; however, the undergraduate sample was signicantly younger than the community sample (mean difference = 7.14; p < .01), which was signicantly younger than the clinical sample (mean difference = 7.94; p < .01), F(2, 1346) = 241.51, p < .01, eta2 = .26. Despite the statistically signicant differences in age, in the undergraduate and community samples the correlations between age and each of the IUS total and subscale scores were not statistically signicant (all ps > .05, all rs < .04). In the clinical sample, the correlations between age and each of the IUS total score, r(355) = .11, p = .03, prospective IU score, r(355) = .11, p = .04, and inhibitory IU score, r(355) = .10, p = .06, while at or approaching statistical signicance, were all very small (Cohen, 1988). Accordingly, age was not considered further in the analyses. GAF scores from the SCIDI used as a measure of diagnostic severity ranged from 40 to 85 across all groups (i.e., PDA 4085; GAD 4878; OCD 5082; SAD 4075; MDD 5080). There were statistically signicant differences in GAF scores across diagnostic groups, F(4, 347) = 3.73, p < .01, eta2 = .04; however, the effect size was relatively small. Following a Tukey correction, persons in the SAD group reported slightly lower scores than persons in the GAD (mean difference = 3.55; p < .05) and OCD (mean difference = 3.65; p < .05) groups. All other group comparisons, including across men and women, t(367) = 1.43, p > .05, r2 < .01, were non-signicant. Given the small differences and effect sizes, as well as the relatively few between group differences, severity was not considered further in the analyses and participants were not further subdivided or analysed based on a sex by GAF interaction. Regarding the IUS-12, there were no items or summed scale alternatives that demonstrated unacceptable levels of skew or kurtosis (i.e., none had positive standardized skewness values that exceeded 2 or positive standardized kurtosis values that exceeded 7; see Curran, West, & Finch, 1996; Tabachnick & Fidell, 2007). There were also almost no statistically signicant differences between men and women (i.e., all ps > .10; r2 s < .01) on the total or subscale scores in any sample. The exception was that men scored slightly higher than women on the inhibitory IU subscale in the community sample, t(569) = 2.25, p < .05, r2 < .01; however, the effect size was extremely small. 2.2. Distribution estimations and ANOVA results The Kernel distribution estimations for all groups are reported in Fig. 1. Three general patterns emerged. First, SAD, GAD, OCD, and MDD groups demonstrated very similar distributions falling within the higher range of IUS-12 scores, and these distributions appeared relatively normal to negatively skewed. Second, the undergraduate

Fig. 1. Kernel density estimation of IUS-12 scores across groups, with density reecting frequency of cases along IUS-12 scores.

and community samples demonstrated very similar distributions to each other that were disparate from the diagnostic groups, and the distributions were positively skewed, centering around lower IUS12 scores. Third, individuals with panic disorder reported a wider range of IUS-12 scores compared to those with other mental disorders and those without. These ndings suggest that variance in the undergraduate and community samples may be attributable to infrequent extremely high IUS-12 scores, while variance in the diagnostic groups is a result of more frequent modest deviations from the mean and some infrequent low IUS-12 scores. The substantially different sample sizes within each of the diagnostic groups in the clinical sample, while not prohibitive for ANOVA, does make meeting the assumption of homogeneity of variance more important (Tabachnick & Fidell, 2007); however, even if violated, a Welch correction can be employed along with discriminating post hoc tests to ensure any statistically signicant differences are likely to be robust (Judd, McClelland, & Culhane, 1995; Tabachnick & Fidell, 2007). In both ANOVAs the assumption of homogeneity was violated (p < .05) for the total score and both subscales of the IUS-12. Accordingly, a Welch correction was applied to all F-values. The rst ANOVA (replicating Ladouceur et al., 1999) collapsed diagnostic groups creating groups with a principal diagnosis of GAD (n = 63; i.e., with or without an additional diagnosis of another anxiety disorder), an additional diagnosis of GAD (n = 49; i.e., another principal diagnosis, but with a concurrent additional diagnosis of GAD), a principal diagnosis of any other anxiety disorder (n = 225; i.e., no principal or additional diagnosis of GAD), a principal diagnosis of MDD (n = 21), the undergraduate sample (n = 428), and the community sample (n = 571). Statistically signicant differences were identied for the total score, F(5, 134.32) = 70.14, p < .001, eta2 = .20, the prospective IU subscale, F(5, 134.61) = 46.05, p < .001, eta2 = .14, and the inhibitory IU subscale, F(5, 134.32) = 83.02, p < .001, eta2 = .23. Tukey post hoc comparisons were conducted to assess for individual differences between group means. The results of the Tukey post hoc comparisons were generally comparable for the total and subscale scores. There were no statistically signicant differences between participants with a principal diagnosis of GAD, an additional diagnosis of GAD, a principal diagnosis of any other anxiety disorder, or a principal diagnosis of MDD (i.e.,

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Table 2 Descriptive statistics. IUS-12 and GAF Score Undergraduates (n = 428) Community (n = 571) SAD (n = 120) PDA (n = 89) GAD (n = 63) OCD (n = 60) MDD (n = 26)

M (SD) Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12 Pro Inh Total GAF 2.14 (1.08) 3.26 (1.07) 2.02 (1.15) 2.49 (1.15) 2.19 (1.14) 1.80 (.97) 2.15 (1.01) 2.77 (1.17) 1.97 (1.08) 2.14 (1.16) 2.69 (1.19) 1.89 (1.05) 17.51 (5.68) 10.00 (4.30) 27.52 (9.28)

S (.12)/K (.24) .70/ .24 .16/ .71 .92/ .09 .40/ .69 .71/ .36 1.09/ .48 .70/ .02 .11/ .84 .91/ .00 .78/ .36 .18/ .91 1.10/ .55 .42/ .15 .94/ .40 .67/ .16

M (SD) 2.25 (1.22) 3.34 (1.21) 2.36 (1.39) 2.79 (1.26) 2.34 (1.27) 2.01 (1.19) 2.36 (1.26) 2.80 (1.35) 2.23 (1.26) 2.26 (1.26) 2.80 (1.25) 2.01 (1.21) 18.54 (6.50) 10.99 (5.23) 29.53 (10.96)

S (.10)/K (.20) .71/ .52 .23/ .93 .63/ .88 .19/ .95 .56/ .80 1.05/ .12 .55/ .80 .18/ 1.12 .73/ .59 .71/ .60 .10/ .98 1.04/ .03 .37/ .53 .81/ .23 .59/ .32

M (SD) 3.69 (1.13) 3.87 (1.07) 3.82 (1.24) 3.32 (1.35) 3.22 (1.39) 3.36 (1.34) 3.69 (1.08) 3.35 (1.27) 3.15 (1.28) 3.64 (1.23) 3.38 (1.25) 3.18 (1.25) 23.97 (6.48) 17.69 (4.75) 41.65 (10.23) 59.52 (7.45)

S (.22)/K (.44) .47/ .78 .78/ .12 .76/ .48 .20/ 1.11 .15/ 1.22 .41/ .98 .63/ .28 .36/ .88 .19/ 1.09 .53/ .74 .35/ .79 .26/ .96 .23/ .56 .64/ .42 .38/ .50

M (SD) 3.25 (1.30) 3.47 (1.35) 3.54 (1.41) 2.99 (1.24) 2.85 (1.43) 2.67 (1.43) 3.06 (1.33) 3.21 (1.34) 2.87 (1.37) 3.07 (1.29) 3.19 (1.35) 2.84 (1.26) 21.83 (7.49) 15.18 (5.55) 37.01 (12.45) 60.08 (8.77)

S (.26)/K (.51) .25/ .98 .46/ .98 .53/ 1.07 .21/ .97 .12/ 1.35 .33/ 1.20 .04/ 1.19 .23/ 1.13 .19/ 1.17 .03/ 1.08 .16/ 1.17 .18/ .82 .07/ .96 .02/ 1.08 .07/ .92

M (SD) 3.64 (1.32) 4.00 (1.11) 3.71 (1.26) 3.62 (1.41) 3.16 (1.32) 2.71 (1.34) 3.17 (1.34) 3.54 (1.50) 3.06 (1.49) 3.21 (1.32) 3.57 (1.34) 2.98 (1.39) 24.60 (6.84) 15.79 (5.19) 40.38 (11.26) 63.06 (7.28)

S (.30)/K (.60) .62/ .83 1.03/ .59 .78/ .41 .68/ .84 .13/ 1.15 .18/ 1.12 .16/ 1.22 .49/ 1.24 .05/ 1.45 .18/ 1.08 .66/ .76 .07/ 1.24 .22/ .92 .16/ .58 .18/ .70

M (SD) 3.27 (1.29) 3.88 (1.09) 3.82 (1.23) 3.52 (1.17) 3.25 (1.35) 3.15 (1.42) 3.58 (1.29) 3.40 (1.36) 2.92 (1.23) 3.53 (1.32) 3.38 (1.43) 3.08 (1.32) 23.62 (6.45) 17.17 (5.28) 40.78 (10.71) 63.17 (7.95)

S (.31)/K (.61) .37/ .86 .82/ .04 .94/ .11 .47/ .50 .30/ 1.16 .20/ 1.28 .63/ .77 .27/ 1.15 .11/ .92 .58/ .69 .28/ 1.33 .25/ 1.14 .28/ .88 .63/ .44 .46/ .35

M (SD) 3.54 (1.07) 3.96 (.96) 3.88 (1.14) 3.62 (1.10) 3.38 (1.33) 3.46 (1.14) 3.85 (.88) 3.69 (1.09) 3.50 (1.17) 3.38 (1.17) 3.54 (1.21) 3.23 (1.27) 25.23 (5.32) 17.81 (4.51) 43.04 (9.20) 59.52 (8.12)

S (.46)/K (.89) .43/ .17 1.10/ 2.11 .80/ .01 .52/ .23 .34/ .84 .51/ .03 .44/ .27 .74/ .10 .64/ .20 .51/ .45 .47/ .93 .22/ .80 .15/ 1.24 .60/ .90 .10/ .64

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Notes: MDD, major depressive disorder; PDA, panic disorder with or without agoraphobia; GAD, generalized anxiety disorder; SAD, social anxiety disorder; OCD, obsessive-compulsive disorder; S, skew; K, kurtosis; IUS-12, Intolerance of Uncertainty Scale-12; IUS-12 Pro, prospective IU subscale; IUS-12 Inh, inhibitory IU subscale; GAF, global assessment of functioning.

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474 R.N. Carleton et al. / Journal of Anxiety Disorders 26 (2012) 468479

all ps > .10). In contrast, all of the aforementioned clinical groupings reported statistically signicantly higher scores than both the undergraduate and community samples (i.e., all ps < .01). There were no statistically signicant differences between the undergraduate and community samples. Given that no differences were found from this rst ANOVA, only the second ANOVA results are presented in detail; however, the results of the rst ANOVA are available from the authors upon request. In the second ANOVA, the comparisons of response means between each of the groups (using principal diagnoses for the clinical sample, but not excluding participants with additional diagnoses) revealed statistically signicant differences for the total score, F(6, 182.90) = 58.59, p < .001, 2 = .20, the prospective IU subscale, F(6, 183.03) = 35.87, p < .001, 2 = .14, and the inhibitory IU subscale, F(6, 182.69) = 73.45, p < .001, 2 = .24. The results of the Tukey post hoc comparisons were generally comparable for the total and subscale scores (i.e., all but two ps > .10). Specically, there were no statistically signicant differences between any of the diagnostic groups within the clinical sample (see Table 2) despite a power analysis indicating sufcient sample sizes to detect differences associated with a medium effect size (i.e., total sample n > 200; moderate effect size of f2 = .25, = .05 (1-tailed), and power = .85). Similarly, there were no differences between the undergraduate and community samples. In contrast, the SAD, PDA, GAD, OCD, and MDD diagnostic groups all reported statistically signicantly higher total scores than both the undergraduate and community samples. Overall, the results suggest that persons with a diagnosis of SAD, PDA, GAD, OCD, or MDD report higher levels of IU than undergraduate and community samples. The exceptions to the Tukey comparisons involved people diagnosed with SAD reporting slightly higher scores on the inhibitory IU subscale (mean difference = 2.51; p < .01) and therein the IUS total score (mean difference = 4.65; p < .05) relative to people diagnosed with PDA. The presence of comorbid diagnoses could have masked differences in IU associated with any single disorder. Consequently, a third ANOVA was performed assessing IU across individuals with only one diagnosis; however, this was not an a priori analysis. In short, the second ANOVA was re-run, but excluded participants with a comorbid diagnosis. The additional criterion further restricted comparative power (i.e., SAD, n = 23, PDA, n = 28; GAD, n = 12; OCD, n = 12; MDD, n = 2; MDD was excluded from the comparisons because of an insufcient sample size of n = 2), so no Type I corrections were used; nevertheless, no statistically signicant (all ps > .05) differences were found between the diagnostic groups. As such, the details of this third ANOVA, including the means and standard deviations, have not been presented but can be requested from the authors. 2.3. Factor analytic results The t indices generally supported the 2-factor structure for men and women in each of the three samples (i.e., clinical, undergraduate, and community); moreover, the 2-factor structure was statistically superior to a unitary structure for men and women in all three samples (Table 3). The t indices also generally supported the 2-factor structure across men and women in each of the three samples; however, relative to the other samples, the clinical sample as a whole had the poorest t indices, possibly due to the relatively higher variability. In any case, the 2-factor structure was, again, statistically superior to a unitary structure in all three samples as measured by chi-square difference tests (Table 3). The sample sizes associated with some of the diagnostic groups within the clinical sample would typically be considered small (i.e., the GAD and OCD groups) or insufcient (i.e., the MDD group) for CFA; nevertheless, in an effort to thoroughly present available data and determine whether a 2-factor or unitary solution would be

superior, all were tested with CFA. The t indices associated with the 2-factor structure were inconsistent and generally did not meet the cut-off indices, as should be expected from relatively small samples. Despite that inconsistency, in all cases the 2-factor structure was consistently signicantly superior to the unitary structure, except for MDD where no difference was found. 2.4. Invariance analyses results There were no differences between men and women based on measurement weights or structural covariances for any of the three samples (Table 4). In other words, the response patterns for men and women were comparable in all three samples (i.e., clinical, undergraduate, and community). Despite all three samples demonstrating comparable response patterns for men and women, the clinical sample demonstrated the least difference between men and women, whereas the undergraduate sample demonstrated the most. As such, men and women were assessed together for the subsequent invariance analyses. There were no differences between the undergraduate and community samples based on measurement weights (Table 4), suggesting the response patterns were largely similar; however, the structural covariances were signicantly different, indicating at least some variance. In contrast, there were signicant and substantial differences in responses patterns based on measurement weights or structural covariances between the clinical sample and each of the undergraduate and community samples. Even though the t indices associated with the 2-factor structure assessed in each diagnostic group were insufcient, likely due to insufcient sample sizes, there were no differences across the diagnostic groups (i.e., SAD, PDA, GAD, OCD, MDD) based on measurement weights or structural covariances. In any case, if there was a robust difference in the response patterns across each diagnostic group, the relatively poor group t indices and small sample sizes should have increased, not decreased, such differences, particularly given how many groups were compared simultaneously. As such, it appears that within the clinical sample the response patterns are invariant across each of the diagnostic groups. 3. Discussion The present study makes three important contributions to the IU literature. First, the study presents the rst direct comparative analyses of IU response patterns and empirical distributions as measured by the IUS-12 across clinical samples of people endorsing criteria for a principal diagnosis of GAD, OCD, SAD, PDA, or MDD relative to undergraduate and community samples. Doing so provided an empirical assessment of how IU may not be specic to any given anxiety disorders or depression, which would shed light on a construct that appears to represent a cognitive vulnerability transdiagnostic across numerous anxiety disorders (Garber & Hollon, 1991; Gentes & Ruscio, 2011; Ingram, 2003; McEvoy & Mahoney, 2011). Second, the same data allowed for the rst presentation of normative IUS-12 data for several clinical samples, and further assessments of the proposed 2-factor model for the IUS-12. Third, the results lend further psychometric support to the IUS-12 as being invariant across sex with a robust factor structure when administered as an independent measure (rather than as a subset of the original IUS). Previous assessments with the IUS-12 (Carleton, Norton, et al., 2007; Khawaja & Yu, 2010; McEvoy & Mahoney, 2011) and with other scales for measuring IU (Carleton, Gosselin, et al., 2010; Gosselin et al., 2008; Robichaud, Dugas, & Conway, 2003) have demonstrated broadly normal distributions with negligible differences in endorsement of IU between men and women, which is

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Table 3 Conrmatory factor analyses t indices. 2-Factor Undergraduate sample Total n

2

Community sample Women 325 145.234 53 2.740 .949 .073 .059; .088 .046 .603 .504; .725 Total 571 182.462 53 3.443 .963 .065 .055; .076 .040 .408 .342; .487 Men 187 97.550 53 1.841 .953 .067 .046; .088 .057 .793 .665; .964 Women 384 140.339 53 2.648 .966 .066 .053; .079 .037 .497 .415; .599

Clinical sample Total 376 244.935 53 4.621 .919 .098 .086; .111 .058 .786 .667; .926 Men 146 106.484 53 2.009 .930 .083 .060; .106 .064 1.079 .903; 1.309 Women 230 188.220 53 3.551 .917 .106 .089; .122 .061 1.040 .874; 1.240

Clinical diagnostic groups SAD 120 133.143 53 2.512 .875 .113 .089; .137 .072 1.539 1.285; 1.857 PDA 89 106.853 53 2.016 .925 .107 .078; .137 .052 1.782 1.491; 2.163 GAD 63 128.570 53 2.426 .805 .152 .118; .185 .106 2.880 2.405; 3.479 OCD 60 80.781 53 1.524 .916 .094 .049; .134 .095 2.217 1.872; 2.696 MDD 26 81.759 53 1.543 .813 .147 .079; .208 .119 5.270 4.448; 6.411 R.N. Carleton et al. / Journal of Anxiety Disorders 26 (2012) 468479

Men 103 92.498 53 1.745 .925 .085 .055; .114 .065 1.397 1.173; 1.698

df
2 /df CFI RMSEA RMSEA CI SRMR ECVI ECVI CI

428 173.933 53 3.282 .948 .073 .061; .085 .046 .524 .440; .627

1-Factor

Undergraduate sample Total Men Women

Community sample Total 308.559 54 5.714 .927 .091 .081; .101 .052 .626 .535; .729 126.097 <.05 Men 133.882 54 2.479 .916 .089 .070; .108 .066 .978 .815; 1.182 36.332 <.05 Women 232.134 54 4.299 .930 .093 .081; .105 .050 .731 .618; .864 91.795 <.05

Clinical sample Total 361.531 54 6.695 .870 .123 .111; .135 .063 1.092 .942; 1.236 116.596 <.05 Men 153.031 54 2.834 .870 .112 .092; .134 .072 1.386 1.158; 1.668 46.547 <.05 Women 260.288 54 4.820 .873 .129 .114; .145 .064 1.346 1.143; 1.582 72.068 <.05

Clinical diagnostic groups SAD 172.295 54 3.191 .815 .136 .113; .159 .082 1.851 1.549; 2.217 39.152 <.05 PDA 121.557 54 2.251 .906 .119 .091; .148 .056 1.927 1.606; 2.335 14.704 <.05 GAD 139.106 54 2.576 .780 .159 .127; .192 .104 3.018 2.517; 3.643 10.536 <.05 OCD 121.106 54 2.243 .797 .145 .111; .180 .093 2.866 2.390; 3.474 40.325 <.05 MDD 82.546 54 1.529 .814 .145 .077; .206 .124 5.222 4.397; 6.365 .787 >.05

258.146 112.116 212.712 54 54 54 df 2 /df 4.780 2.076 3.939 .912 .890 .913 CFI .103 .095 RMSEA .094 RMSEA CI .083; .106 .076; .130 .082; .109 .055 .071 .055 SRMR .717 1.570 .805 ECVI .609; .843 1.310; 1.906 .678; .955 ECVI CI Comparing 2-factor and unitary structures 2 84.213 19.618 67.478 <.05 <.05 p <.05

Notes: CFI, Comparative Fit Index; SRMR, Standardized Root Mean Square Residual; RMSEA, Root Mean Square Error of Approximation; ECVI, Expected Cross-Validation Index; CI, 90% condence intervals; MDD, major depressive disorder; PDA, panic disorder with or without agoraphobia; GAD, generalized anxiety disorder; SAD, social anxiety disorder; OCD, obsessive-compulsive disorder.

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476 Table 4 Invariance analyses. Sample(s) Clinical (n = 358) Undergraduate (n = 428) Community (n = 571) Undergraduate and community Clinical and undergraduate Clinical and community Clinical Comparison groups Menwomen Menwomen Menwomen Undergraduate-community Clinical-undergraduate Clinical-community MDDPDAGADSADOCD Measurement weights
2 2

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Structural covariances (3) = .85, p = .84 (3) = .87, p = .83 (3) = 3.85, p = .28 2 (3) = 16.99, p < .01 n/a n/a 2 (12) = 17.66, p = .13
2 2 2

(10) = 10.05, p = .43 (10) = 17.70, p = .06 2 (10) = 13.43, p = .20 2 (10) = 11.83, p = .30 2 (10) = 33.92, p < .01 2 (10) = 35.44, p < .01 2 (40) = 34.14, p = .73

Invariant Invariant Invariant Partially variant Variant Variant Invariant

Notes: MDD, major depressive disorder; PDA, panic disorder with or without agoraphobia; GAD, generalized anxiety disorder; SAD, social anxiety disorder; OCD, obsessivecompulsive disorder. Assumes measurement weights were correct and should not be interpreted it the measurement weights were not invariant; invariance is indicated by a lack of statistical signicance.

supported by the current ndings. To further assess for potential differences between men and women, the 2-factor structure was assessed using an invariance analysis (Byrne, 2001, 2004). The invariance analyses, which are quite stringent, produced no differences between men and women, providing evidence that the endorsement patterns for men and women appear comparable irrespective of whether the sample is broad (i.e., undergraduate or community) or range-restricted (i.e., clinical). As such, IU as measured by the IUS-12 appears to be a ubiquitous construct, generally indiscriminant based on sex. People in the clinical sample were expected to endorse higher levels of IU than people in the undergraduate and community samples. As expected, people with a principal diagnosis of SAD, PDA, GAD, OCD, or MDD endorsed signicantly higher levels of IU than did people in the undergraduate and community samples. There were no differences between the undergraduate and community samples. Furthermore, the empirical distributions of IU for those with a principle diagnosis of SAD, GAD, OCD and MDD were very similar, suggesting that the groups of individuals with these disorders reported not only similar levels of intolerance of uncertainty, but that IU shares a relatively symmetrical distribution across all of these disorders. Nevertheless, these ndings did not generalize to those with PDA, as they reported a relatively larger variance of scores compared to those with other disorders and undergraduate and community participants. These ndings are congruent with previous ndings suggesting that IU may be associated with PDA differently than in other anxiety disorders or depression (Norton & Mehta, 2007). Future research may benet from examining the specic distribution of IU within a larger PDA sample. Based on the theoretical position that IU is a characteristic feature unique to GAD or OCD, participants endorsing either disorder as principal were expected to report higher levels of IU relative to participants endorsing other disorders as principal (Dugas et al., 2004; Ladouceur et al., 2000; Lind & Boschen, 2009; Tolin et al., 2003); however, there were almost no statistically signicant differences between any of diagnostic groups within the clinical sample. There were also no statistically signicant differences when the Ladouceur et al. (1999) analyses were replicated. Specifically, there were no differences in IU scores between persons with principal diagnosis of GAD, an additional diagnosis of GAD, a principal diagnosis of any other anxiety disorder, or a principal diagnosis of MDD. There were also no differences in IU scores between the undergraduate sample, and the community sample. An exception to the comparability of IU across clinical samples involved people with a principal diagnosis of SAD who reported slightly higher scores on the inhibitory IU subscale than those with a principal diagnosis of PDA. Differential associations between the subscales and symptoms are not unprecedented. Previous results have associated prospective IU with GAD and OCD (i.e., anticipation of uncertainty; McEvoy & Mahoney, 2011), and associated inhibitory IU with panic, SAD, and depression (i.e., uncertainty

produces inhibition; Carleton, Gosselin, et al., 2010; McEvoy & Mahoney, 2011). As speculated implicitly by some (Miranda et al., 2008; Yook et al., 2010) and explicitly by McEvoy and Mahoney, while IU appears to be a transdiagnostic maintaining mechanism, [prospective IU and inhibitory IU] may play different roles across different disorders (2011, p. 121). In any case, the general comparability of endorsement rates, patterns, and distributions, suggests against IU as an underlying feature of only worry-specic anxiety disorders such as GAD and some OCD. Instead, the results lend further support to postulate that IU may be a broad vulnerability factor for most anxiety disorders and depression (Boelen et al., 2010; Butzer & Kuiper, 2006; Carleton, Sharpe, et al., 2007; McEvoy & Mahoney, 2011; Yook et al., 2010). Previous research has supported the proposed 2-factor structure of the IUS-12 as being robust across undergraduate samples (Carleton, Norton, et al., 2007; Carleton, Sharpe, et al., 2007) and recently supported the same structure in a broad sample of people seeking treatment for anxiety disorders (McEvoy & Mahoney, 2011). In the current study, the 2-factor structure (i.e., prospective IU and inhibitory IU) was supported in all three samples and the t indices were superior to a unitary alternative. The sample sizes for each of the diagnostic groups within the clinical sample would typically be considered insufcient for robust CFA; however, the preliminary analyses nonetheless supported the 2-factor structure relative to a unitary structure for each diagnostic group within the clinical sample, except for MDD where no difference was found. The results of the multi-group invariance analyses across the samples (i.e., clinical, undergraduate, and community) and across the diagnostic groups with the clinical sample (i.e., SAD, PDA, GAD, OCD, MDD) were relatively denitive. The response patterns of undergraduate and community participants were largely comparable. In contrast, the response patterns of clinical participants were substantially different from each of the undergraduate and community participants, with the differences themselves being comparable in magnitude. The results suggest not only do clinical participants endorse higher rates of IU than undergraduate and community participants, but the pattern of their endorsement (i.e., across prospective and inhibitory IU subscales) is also different. When comparing diagnostic groups within the clinical sample, there were no differences in the pattern of responding. It could be argued that the multi-group invariance analyses for the diagnostic groups within the clinical sample may not be robust because (1) even though the two-factor structure was superior to a unitary alternative, it was not robustly supported and (2) the sample sizes for many of the diagnostic groups were relatively small; however, if there was a robust difference in the response patterns across each diagnostic group, the somewhat poor group t indices and small sample sizes should have increased, not decreased, such differences, particularly given how many groups were compared simultaneously. The fact that the diagnostic groups were invariant despite these concerns serves to underscore the comparability

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of the response patterns across the diagnostic groups within the clinical sample. The current results suggest a need to reevaluate the concept that IU may be specic primarily to worry and GAD. The relationship between these variables is well-supported (Buhr & Dugas, 2006, 2009; Sexton et al., 2003); however, rather than being a dispositional construct that works to differentiate diagnoses of GAD from other disorders (Dugas, Marchand, et al., 2005; Ladouceur et al., 1999; Sexton et al., 2003), there is growing evidence that IU is an important component of several disorders (Boelen & Reijntjes, 2009; Buhr & Dugas, 2009; Carleton, Collimore, et al., 2010; Carleton, Sharpe, et al., 2007; Gentes & Ruscio, 2011; McEvoy & Mahoney, 2011; Norton & Mehta, 2007; Norton et al., 2005). Indeed, prior ndings of IU being specic to GAD may well be the result of the original IUS having GAD-specic items (Carleton, Gosselin, et al., 2010; Gentes & Ruscio, 2011). The theoretical rationale for the importance of uncertainty in psychopathology (Brown & Barlow, 2009; Carleton, Sharpe, et al., 2007; McEvoy & Mahoney, 2011), the implied necessity for uncertainty in anxiety (Surez et al., 2009), along with evidence of comparable response patterns and endorsements of IU across anxiety disorders and depression, suggest IU may t well within current transdiagnostic perspectives (Brown & Barlow, 2009; Norton & Philipp, 2008). Transdiagnostic approaches to psychological disorders suggest that they are facilitated or maintained by similar underlying vulnerabilities that should be represented across diagnostic categories. The most basic of underlying vulnerabilities should be inherently noxious (Reiss & McNally, 1985; Taylor, 1993) and evolutionarily supported as threatening (Confer et al., 2010; Epstein, 1972), thus requiring no prior learning. The IU construct seems to meet the aforementioned criteria and uncertainty has been theorized as a key distinguishing feature at least for anxiety; accordingly, there appears to be growing support for the notion that IU may be a transdiagnostic vulnerability factor. Nevertheless, there is a paucity of research examining the specic nature of IU within anxiety-disorders and depression, and if individuals with these disorders experience greater intolerance of uncertainty in general, or specic only to their disorder (e.g., to bodily sensations in panic). There are empirically supported treatments, developed specifically for GAD-related worry that focus on IU (Koerner & Dugas, 2006; Robichaud & Dugas, 2006). Given the seemingly ubiquitous nature of IU, incorporating IU-specic treatment components into therapeutic protocols may result in pervasive benets, and not only for those with GAD or OCD, but for people with any anxiety disorder or with depression. There is already evidence that GAD symptom reporting shifts up or down based on increases and decreases in IU (Ladouceur et al., 2000); accordingly, additional research on the application of IU-specic treatments (e.g., in vivo exposure to uncertainty) across the anxiety disorders seems theoretically and clinically warranted. The current investigation includes several limitations that warrant consideration in interpretation of ndings. These limitations may also provide directions for future research. First, the clinical sample, while relatively large, included diagnostic groups that were relatively less represented (e.g., MDD, which may limit the generalizability of these ndings to such samples). The differences in sizes of diagnostic group were not prohibitive for most of the current analyses; however, the normative values and CFA t indices associated with the smaller diagnostic groups may be less robust than those from larger diagnostic groups. Similarly, several diagnostic categories were excluded due to sample size limitations (i.e., specic phobia, ADNOS) or because the disorder was not treated at the treatment center at which participants sought treatment (i.e., PTSD). Recent research has provided evidence for the role of IU in eating disorders (Konstantellou, Campbell, Eisler, Simic, & Treasure, 2011; Sternheim, Startup, & Schmidt, 2011), complicated grief, and

PTSD (Boelen, 2010); as such, future research should assess these categories as well. Second, there was no interrater reliability information available for diagnosticians using the SCID-I; however, the diagnostic methods, as described in Section 1, are in line with current best practice and assessors received extensive training on the administration of the SCID-I. Third, making comparisons based on the principal diagnosis, while epidemiologically valid, may have masked differences between diagnostic groups that would only appear with larger samples of people with only one diagnosis. In other words, it is possible that the presence of additional diagnoses (as summarized in Table 1) within each diagnostic group may have affected results (e.g., people with SAD may have higher IU scores than people with panic because of higher rates of comorbid GAD). The preliminary attempt at analyzing pure diagnostic samples (i.e., those with only one diagnosis) presented in the current study involved relatively small samples and, while the results continue to indicate no substantive differences in IU between anxiety disorders and depression, larger pure samples or more dynamic assessments of comorbidity may yet produce different results; however, such a possibility is seemingly unlikely. Fourth, there is a single taxometric investigation of latent worry (Olatunji, Broman-Fulks, Bergman, Green, & Zlomke, 2010) and a single taxometric investigation of IU as measured by the IUS-12 (Carleton et al., 2012); however, the construct may yet benet from further taxometric analyses within individual diagnostic groups. Fourth, neither the undergraduate sample nor the community sample was diagnostically assessed. As such, there may have been a disproportionate number of persons with clinically signicant symptoms in both of those samples; however, if that were the case and of sufcient size to warrant concern, it would have increased the probability that the community sample endorsement rates would be statistically comparable to the clinical sample. Instead, the community sample endorsement rates were signicantly lower than the clinical sample and indeed comparable to the undergraduate sample. As such, we suggest the presence of some persons with clinically signicant anxiety in the undergraduate and community samples did not substantially impact the current results. Fifth, determining a specic causal role of IU in the development of anxiety disorders and depression awaits a comprehensive longitudinal investigation. Sixth, investigations of the manner in which IU relates to each of the disorders were not possible. Such investigations may be particularly important given implications that each subscale, prospective IU and inhibitory IU, may interact differently with each disorder. Seventh, despite indications of the comparability of the IUS and the IUS-12, there remains a paucity of direct comparisons between the two measures (Khawaja & Yu, 2010). Researchers have speculated that the IUS, like the new Intolerance of Uncertainty Index, may better account for symptoms of worry (Gentes & Ruscio, 2011), whereas the IUS-12 focuses exclusively on measuring the core IU construct (Carleton, Gosselin, et al., 2010); however, such speculation remains to be empirically assessed. Eighth, the samples were primarily Caucasian, which may limit the generalizability of the results; however, the evidence to date suggests against differences based on ethnicity (Norton, 2005). Despite the limitations, the current study accomplishes several important incremental goals associated with IU research that allow for conclusions that advance this area. First, there were no differences in endorsement patterns across a variety of diagnostic groups despite the use of stringent procedures and sample sizes that should have exacerbated differences; however, there were differences in endorsement patterns between clinical and nonclinical samples. Second, the 2-factor structure of the IUS-12 appears to be robust in clinical, undergraduate, and community samples, with no differences in endorsement rates or patterns for

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478 R.N. Carleton et al. / Journal of Anxiety Disorders 26 (2012) 468479 anxiety, and depression. Personality and Individual Differences, 41, 167176. doi:10.1016/j.paid.2005.12.017 Byrne, B. (2001). Structural equation modeling with AMOS: basic concepts, applications, and programming. Mahwah, NJ: Erlbaum. Byrne, B. (2004). Testing for multigroup invariance using AMOS graphics: a road less traveled. Structural Equation Modeling, 11, 272300. doi:10.1207/s15328007sem1102 8 Carleton, R. N., Abrams, M. P., Asmundson, G. J. G., Antony, M. M., & McCabe, R. (2009). Pain-related anxiety across anxiety and depressive disorders. Journal of Anxiety Disorders, 23, 791798. Carleton, R. N., Collimore, K. C., & Asmundson, G. J. G. (2010). Its not just the judgements its that I dont know: intolerance of uncertainty as a predictor of social anxiety. Journal of Anxiety Disorders, 24, 189195. doi:10.1016/j.janxdis.2009.10.007 Carleton, R. N., Gosselin, P., & Asmundson, G. J. G. (2010). The intolerance of uncertainty index: replication and extension with an English sample. Psychological Assessment, 22, 396406. doi:10.1037/a0019230 Carleton, R. N., Norton, M. A., & Asmundson, G. J. G. (2007). Fearing the unknown: a short version of the intolerance of uncertainty scale. Journal of Anxiety Disorders, 21, 105117. doi:10.1016/j.janxdis.2006.03.014, pii:S0887-6185(06)00051-X Carleton, R. N., Sharpe, D., & Asmundson, G. J. G. (2007). Anxiety sensitivity and intolerance of uncertainty: requisites of the fundamental fears? Behaviour Research and Therapy, 45, 23072316. doi:10.1016/j.brat.2007.04.006, pii:S0005-7967(07)00095-2 Carleton, R. N., Weeks, J. W., Howell, A. N., Asmundson, G. J. G., Antony, M. M., & McCabe, R. E. (2012). Assessing the latent structure of the intolerance of uncertainty construct: An initial taxometric analysis. Journal of Anxiety Disorders, 26, 150157. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). 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men and women. Third, the results provide clinical norms for IU across a variety of diagnostic groups. Fourth, persons with diagnoses of SAD, GAD, OCD, or MDD reported comparable levels of IU that were signicantly and substantially higher than undergraduate and community samples; however, the distribution of IU in PDA may differ from the other disorders, and warrants additional research. Overall, the results indicate that IU represents a construct that may be transdiagnostic across anxiety disorders and depression, and that these disorders share relatively similar levels and distributions of IU. The results suggest against IU having a disorder-specic pattern of endorsement and suggest against IU being specic to GAD or OCD. The current results do not necessarily contrast with previous research exploring differences in IU across disorders using either the IUS or the IUS-12. Findings using the IUS have, to date, been mixed and provide evidence of IU being associated with a variety of symptoms and disorders (Boelen et al., 2010; Butzer & Kuiper, 2006; Carleton, Sharpe, et al., 2007; Dugas, Marchand, et al., 2005; Norton & Mehta, 2007; Norton et al., 2005; Sexton et al., 2003; Yook et al., 2010). Previous results with the IUS-12 also indicate IU is broadly applicable to anxiety and possibly mood disorders (McEvoy & Mahoney, 2011). The substantial overlap in measurement and comparable psychometric substantiation for the IUS and IUS-12 (Carleton, Norton, et al., 2007; Carleton, Sharpe, et al., 2007) supports speculation that previous inconsistencies in IU across disorders may be the result of (1) IUS items that are serendipitously GAD-specic (e.g., My mind cant be relaxed if I dont know what will happen tomorrow) that have been excluded from the IUS-12 in favour of measuring only the core IU construct, (2) using smaller clinical samples, or (3) the use of nonclinical samples. Irrespective of the reason, and until a similarly large-scale clinical comparison of the IUS and IUS-12 is conducted, the current study appears to provide additional broad evidence supporting the importance of IU in several disorders. Indeed, IU may represent a ubiquitous vulnerability factor that ts well within current transdiagnostic perspectives of psychopathology. References
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