A patient’s ability to tolerate uncertainty, or the fear of the unknown, may have a substantial impact on his or her experience of anxiety and mood, as well as direct and indirect perceptions of health.1 Intolerance of uncertainty may, at its core, represent a long-recognized, deep-seated fear.
Originally thought to be specific to generalized anxiety disorder, intolerance of uncertainty also plays an important role in panic disorder, social anxiety disorder, health anxiety, and depression. If physicians know how well their patients tolerate uncertainty about health before providing feedback during a consultation, they can improve their patients’ care dramatically.
Longitudinal evidence indicates that changes in intolerance of uncertainty precede changes in anxiety disorder symptoms. There also is a large body of cross-sectional evidence in several anxiety disorders and in depression. The theoretical basis for the influence of intolerance of uncertainty appears logically sound and defensible from a variety of perspectives.
Evidence suggesting that intolerance of uncertainty is associated with disorders other than generalized anxiety disorder has been growing since 2003. More than 2 dozen recent articles indicate that intolerance of uncertainty plays an important role in panic disorder, social anxiety disorder, health anxiety, and depression. In addition, a recent 58-article meta-analysis found no support for the idea that intolerance of uncertainty is specific to generalized anxiety disorder.2
Instead, there is growing evidence that intolerance of uncertainty can explain variance in symptoms even after controlling for neuroticism, anxiety sensitivity, fear of anxiety, meta-beliefs, and positive and negative affectivity. There also is evidence to suggest that intolerance of uncertainty may be independently related to biophysical responses, such as startle under threat.
Incorporating Intolerance of Uncertainly Into Treatment
Physicians understand the importance of words chosen and inflections used, given the weight patients may put on their interactions. Accordingly, being cognizant that patients will have different capacities to tolerate the inherent uncertainty associated with physical symptoms—and health in general—may improve rapport and patient care and reduce unnecessary health care system strain.
How this cognizance manifests into specific physician-patient interactions varies with the presenting patient and problem. For example, a patient with benign symptoms and a high tolerance for uncertainty may benefit from a response such as “It’s probably nothing, let me know if it gets worse, but in the interim try not to worry about it.” In contrast, a similar patient with a low tolerance for uncertainty may find the same response extremely anxiety-provoking and distressing, resulting in additional visits, tests, and a poorer quality of life.
Knowing how well a patient tolerates uncertainty about health before providing feedback could dramatically improve care. If the physician is unfamiliar with the patient, this could be accomplished by administering a short questionnaire on intolerance of uncertainty in the reception area or by asking a few simple but innocuous questions about how the patient prefers to receive health information. For familiar patients for whom the physician has evidence of low tolerance for uncertainty that is manifesting in impairment, such as repeated unnecessary reassurance-seeking, the physician could consider referral to an anxiety disorder specialist. I am working on research to provide more direct recommendations for intolerance of uncertainty.
What Primary Care Physicians Should Know
Helping patients understand and cope with uncertainty may be beneficial for those who have anxiety disorders, mood disorders, or general health conditions. Physicians can work to remove or minimize an actual imminent threat; definitively correct misinformation about a perceived threat; and increase a patient’s ability to cope with a threat or the associated uncertainty or both. Uncertainty itself may well be the problem and, as such, a successful intervention may depend on helping a patient learn to tolerate uncertainty.
1. Carleton RN. The intolerance of uncertainty construct in the context of anxiety disorders: theoretical and practical perspectives. Expert Rev Neurother. 2012;12:937-947.
2. Gentes EL, Ruscio AM. A meta-analysis of the relation of intolerance of uncertainty to symptoms of generalized anxiety disorder, major depressive disorder, and obsessive-compulsive disorder. Clin Psychol Rev. 2011;31:923-933.