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Intolerance of uncertainty andemotional distress following the deathof a loved onePaul Boelen aa Department of Clinical and Health Psychology , UtrechtUniversity , Utrecht, The NetherlandsPublished online: 05 Jan 2010.

To cite this article: Paul Boelen (2010) Intolerance of uncertainty and emotional distress followingthe death of a loved one, Anxiety, Stress, & Coping: An International Journal, 23:4, 471-478, DOI:10.1080/10615800903494135

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BRIEF REPORT

Intolerance of uncertainty and emotional distress following the deathof a loved one

Paul Boelen*

Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands

(Received 22 July 2009; final version received 16 November 2009)

Research has shown that intolerance of uncertainty (IU) � the tendency to reactnegatively to situations that are uncertain � is involved in worry and generalizedanxiety disorder, as well as in other anxiety symptoms and disorders. To ourknowledge, no studies have yet examined the association between IU andemotional distress connected with the death of a loved one. Yet, it seems plausiblethat those who have more difficulties to tolerate the uncertainties that oftentimesoccur following such a loss experience more intense distress. The current studyexamined this assumption, using self-reported data from 134 bereaved indivi-duals. Findings showed that IU was positively and significantly correlated withsymptom levels of complicated grief and posttraumatic stress disorder (PTSD),even when controlling for time since loss (the single demographic/loss-relatedvariable associated with symptom levels), and for neuroticism and worry, whichare both correlates of IU. Furthermore, IU was specifically related with worry andsymptom levels of PTSD, but not complicated grief, when controlling the sharedvariance between worry, complicated grief severity, and PTSD-severity. Thepresent findings complement prior research that has shown that IU is a cognitivevulnerability factor for worry, and indicate that it may also be involved inemotional distress following loss.

Keywords: intolerance of uncertainty; bereavement; worry; complicated grief;posttraumatic stress disorder

During the past decade, researchers’ interest in the concept intolerance of

uncertainty (IU) has markedly increased. IU has been defined as ‘‘a cognitive bias

that affects how a person perceives, interprets, and responds to uncertain situations

on a cognitive, emotional, and behavioral level’’ (Dugas, Schwartz, & Francis, 2004,

p. 835). People high in IU experience the possible occurrence of future negative

events as stressful, believe that uncertainty is negative, reflects badly on a person,

should be avoided, and have difficulties functioning well in uncertain situations.

There is a wealth of evidence that IU is an important cognitive vulnerability factor

for worry and generalized anxiety disorder (Koerner & Dugas, 2008). However, IU

has also been found to be related to symptoms of obsessive compulsive disorder

(Holaway, Heimberg, & Coles, 2006) and social anxiety (Boelen & Reijntjes, 2009),

even when controlling for concomitant symptom levels of generalized anxiety

disorder. These findings suggest that IU may also be involved in the development

*Email: p.a.boelen@uu.nl

ISSN 1061-5806 print/1477-2205 online

# 2010 Taylor & Francis

DOI: 10.1080/10615800903494135

http://www.informaworld.com

Anxiety, Stress, & Coping

Vol. 23, No. 4, July 2010, 471�478

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and maintenance of anxiety disorders, and symptoms other than worry and

generalized anxiety disorder.

To our knowledge, no studies have yet examined the association of IU with

emotional problems following stressful life events such as the death of a close relative.

Yet, given that such a loss is likely to lead to numerous changes and uncertainties, it

seems plausible to assume that people with higher levels of IU who have moredifficulties to tolerate these changes and uncertainties experience more severe

emotional problems following such loss. The present study examined this assumption.

Specifically, using data from people confronted with the death of a close loved one, we

examined (1) associations of IU with symptom levels of complicated grief and

bereavement-related posttraumatic stress disorder (PTSD). Complicated grief, also

termed Prolonged Grief Disorder, is a disorder of grief characterized by persistent

separation distress (e.g., yearning), difficulties accepting the loss, and difficulties

moving on without the lost person (Prigerson & Jacobs, 2001). Bereavement-related

PTSD is characterized by intrusive images related to the loss, fear-driven avoidance of

reminders of the loss, and hyperarousal. On the condition that we would find

significant correlations between IU and symptom levels of complicated grief and

PTSD, we also planned to examine (2) the extent to which IU continued to be

associated with complicated grief and PTSD severity scores when controlling for

relevant background variables, neuroticism and worry � which are both important

correlates of IU (cf. Norton, Sexton, Walker, & Norton, 2005) � and the shared

variance between these symptom levels. Finally, to further enhance our understanding

of the specificity versus generality of IU, we examined (3) the specificity of IU to

worry, complicated grief severity, and PTSD severity.

Method

Data were used from 134 bereaved people recruited in the context of a larger research

program examining cognitive processes in grief. All participants were recruited via

Dutch Internet sites about loss and grief that solicited people who had lost a close

relative to participate by completing questionnaires. In total, 586 Wave

1 questionnaires were sent out. Four hundred and nine (69.8%) mourners completed

these questionnaires, 337 (82.4%) of whom also completed a Wave 2 questionnaire

package that was sent to them immediately on receipt of their Wave 1 questionnaires.

Data on symptom levels of complicated grief and PTSD that were used in the current

study were obtained from this Wave 2 package. Two hundred and forty people were

also sent a Wave 3 questionnaire package immediately on receipt of their Wave 2questionnaires. This Wave 3 package included the measures of IU, worry, and

neuroticism that were used in the current study. One hundred and fifty (62.5%) were

returned. To increase homogeneity of the sample, participants whose losses had

occurred more than 10 years ago (N�16) were not included in the present analyses.

Thus, the final sample included N�134 bereaved people. Table 1 shows their

demographic and loss-related characteristics. Most participants were women, about

a third had lost a partner, and losses were mostly due to illness. The present study

was approved by a local review board and informed consent was obtained from all

participants.

IU was measured with the 27-item Intolerance of Uncertainty Scale (IUS)

developed by Freeston, Rheaume, Letarte, Dugas, and Ladouceur (1994); Dutch

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version by De Bruin, Rassin, van der Heiden, and Muris (2006). Respondents rate

the degree to which 27 statements reflecting IU (e.g., ‘‘Being uncertain means that

I am not first rate’’, ‘‘I can’t stand being taken by surprise’’) apply to them on five-

point scales ranging from one (not at all characteristic of me) to five (entirely

characteristic of me).

Worry was measured with the Penn State Worry Questionnaire (PSWQ) (Meyer,

Miller, Metzger, & Borkovec, 1990; Dutch version by van Rijsoort, Emmelkamp, &

Vervaeke, 1999). This measure asks respondents to rate to what extent 16 items

reflecting worry are typical of them on five-point scales ranging from one (not at all

typical of me) to five (very typical of me).

Neuroticism was assessed using the Shortened Eysenck Personality Questionnaire

neuroticism subscale (EPQ-N; Eysenck, Eysenck, & Barrett, 1985; Dutch version by

Sanderman, Arrindell, Ranchor, Eysenck, & Eysenck, 1995). Respondents indicate

their agreement with 12 neuroticism items using a forced-choice response format (yes

vs. no).

Symptom levels of complicated grief were assessed with the Inventory of

Complicated Grief-revised (ICG-r) developed by Prigerson and Jacobs (2001) and

validated in Dutch by Boelen, van den Bout, De Keijser, and Hoijtink (2003). In this

measure, respondents rate the degree to which 29 symptoms of complicated grief and

other debilitating grief reactions were present during the last month on a scale from

one (never) to five (always).

Table 1. Characteristics and symptom scores of the sample (N�134).

Demographic characteristics

Gender (N (%))

Men 14 (10.4)

Women 120 (89.6)

Age (years) (M (SD)) 43.8 (11.2)

Age range (years) 20�62

Highest education (N (%))

Primary school 13 (9.7)

Secondary school 41 (30.6)

College/University 80 (59.7)

Loss characteristics

Deceased is (N (%))

Partner 40 (29.9)

Child 20 (14.9)

Parent 41 (30.6)

Other relative 33 (24.6)

Cause of death is (N (%))

Illness 69 (51.5)

Violent (accident, suicide, homicide) 14 (10.4)

Unexpected medical cause (e.g., heart attack) 35 (26.1)

Other cause 16 (11.9)

Time since loss (months) (M (SD)) 23.8 (28.3)

Time since loss range (months) 1�120

Note: Some numbers do not add up to 134, due to occasional missing values.

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Finally, PTSD severity was assessed using the PTSD Symptom Scale Self-Report

version (PSS-SR) developed by Foa, Riggs, Dancu, and Rothbaum (1993); Dutch

version by Engelhard, Arntz, and van den Hout (2007). Respondents rate the

frequency of 17 PTSD symptoms in the previous month on four-point scales ranging

from zero (not at all) to three (five or more times per week/almost always). In the

present study the index event was defined as ‘‘the death of your loved one.’’

Cronbach’s alphas of the measures and means and SDs are shown in Table 2.

Results

Because we wanted to control for relevant demographic and loss-related variables in

the regression analyses described below, it was first examined to what extent the

severity of complicated grief (ICG-r) and PTSD (PSS-SR) varied as a function of

demographic and loss-related variables. Time since loss was negatively correlated

with PSS-SR scores (r��.23, pB.01). The linkage of time since loss with ICG-r

scores was also negative, but only marginally significant (r��.16, pB.06). ICG-r

and PSS-SR scores were not associated with any of the other demographic/loss-

related variables.

Next, correlations between study measures were calculated. These are shown inTable 2. Among other things, correlations showed that IU was strongly and

significantly associated with worry and neuroticism. More pertinent to the aims of

the current study, IU was significantly correlated with symptom levels of complicated

grief and PTSD.

Hierarchical regression analyses were then carried out to examine whether or not

IU continued to be associated with complicated grief and PTSD scores, when

controlling for time since loss (the single relevant background variable associated

with complicated grief and PTSD) and for neuroticism and worry. Outcomes are

summarized in Table 3. A first regression predicting complicated grief scores showed

that time since loss, neuroticism, and worry entered in Step 1 explained 24.7% of the

variance in complicated grief (DF (3, 118)�12.90, pB.001). Time since loss,

neuroticism, and worry each made a unique contribution to the explained variance in

complicated grief. IU added 2.4% to the explained variance in complicated grief

Table 2. Correlations and descriptive statistics (N�134).

Variable 1 2 3 4 5

1. Intolerance of Uncertainty (IUS) �2. Worry (PSWQ) .62* �3. Neuroticism (EPQ-N) .55* .59* �4. Complicated grief (ICG-r) .44* .43* .43* �5. Posttraumatic stress (PSS-SR) .47* .44* .42* .81* �M 56.64 46.82 4.93 66.91 14.73

SD 18.32 12.24 3.81 20.54 8.43

Cronbach’s alpha .94 .91 .87 .94 .88

Note: EPQ-N, Shortened Eysenck Personality Questionnaire, neuroticism scale; ICG-r, Inventory ofcomplicated grief-revised version; IUS, Intolerance of Uncertainty Scale; PSS-SR, posttraumatic stressscale-self report version; PSWQ, Penn State Worry Questionnaire.*pB.001.

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in Step 2 (DF (1, 117)�3.92, pB.05). Time since loss and IU were unique correlates

of complicated grief in this final model (see Table 3). A second regression predicting

PTSD severity showed that time since loss, neuroticism, and worry, entered in Step 1,

explained 28.1% of the variance in PTSD scores (DF (3, 118)�15.35, pB.001). Time

since loss, neuroticism, and worry each made a unique contribution to the explained

variance. IU, entered in Step 2, added 5.2% to the explained variance in PTSD

(DF (1, 117)�9.15, pB.01). Time and IU explained unique variance in this second

and final model (see Table 3).

Two additional hierarchical regression analyses were conducted to examine if IU

remained significantly correlated with complicated grief and PTSD when we also

controlled for concomitant symptom levels. In a third hierarchical regression

analysis, complicated grief was regressed on time, neuroticism, and worry (again

entered in Step 1), followed by PTSD scores entered in Step 2, and IU entered in

Step 3. Outcomes showed that PTSD severity added 39.4% to the explained

variance in complicated grief in Step 2 (DF (1, 117)�128.53, pB.001). PTSD

severity was the only uniquely correlate of complicated grief in this second

model (b�.74, pB.001). IU did not explain extra variance in Step 3 (DR2�.00,

DF (1, 116)�.06, p�.81). PTSD severity remained the only unique correlate of

complicated grief scores in this third and final model (b�.75, pB.001).

A similar analysis was done with PTSD severity serving as dependent variable and

concomitant complicated grief now being entered in Step 2. Outcomes showed that

complicated grief severity added 37.7% to the explained variance in PTSD severity in

Step 2 (DF (1, 117)�128.53, pB.001). Time (b��.11, pB.05) and complicated

grief severity (b�.71, pB.001) were unique correlates of PTSD severity in this

second model. IU added a small but significant amount of 1.4% extra variance

in PTSD severity in Step 3 (DF (1, 116)�5.08, pB.05). In this final model, time

Table 3. Summary of hierarchical regression analyses for variables predicting complicated

grief and posttraumatic stress disorder severity (N�134).

Complicated grief severity

Posttraumatic stress

disorder severity

Variable b DR2 b DR2

Step 1 .247*** .281***

Time since loss �.17* �.23**

Worry (PSWQ) .24* .21*

Neuroticism (EPQ-N) .30** .34**

Step 2 .024* .052**

Time since loss �.19* �.26**

Worry (PSWQ) .19 .13

Neuroticism (EPQ-N) .20 .20

Intolerance of

Uncertainty (IUS)

.21* .30**

Note: EPQ-N, Shortened Eysenck Personality Questionnaire, neuroticism scale; ICG-r, Inventory ofcomplicated grief-revised version; IUS, Intolerance of Uncertainty Scale; PSS-SR, Posttraumatic stressscale-self report version; PSWQ, Penn State Worry Questionnaire.*pB.05; **pB.01; ***pB.001.

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(b��.13, pB.05), complicated grief severity (b�.68, pB.001), and IU (b�.16,

pB.05) were unique correlates of PTSD symptom severity.

Finally, to further address the specificity of IU to worry and symptom levels of

complicated grief and PTSD, a final regression was run in which IU scores were

regressed on worry scores (PSWQ), complicated grief scores (ICG-R), and PTSD

scores (PSS-SR) entered simultaneously, again also controlling for time since loss. Allvariables together accounted for 43.8% of the variance in IUS scores (F (4, 123)�23.94, pB.001). Time since loss (b�.14, pB.05), worry (b�.48, pB.001), and

symptom levels of PTSD (b�.23, pB.05), but not symptom levels of complicated

grief (b�.05) made a unique contribution to the explained variance in IU.

Discussion

To our knowledge, this is the first study to investigate the linkage between IU and

emotional problems following the death of a loved one. Replicating previous work,

findings showed that IU was significantly and positively associated with neuroticism

and worry (e.g., Norton et al., 2005). More pertinent to the aims of the current study,

IU was also significantly positively associated with symptom levels of complicated

grief and loss-related PTSD. IU continued to explain variance in symptom levels ofcomplicated grief and PTSD when we controlled for time since loss (the only

demographic/loss-related variable that was associated with symptom scores) as well

as for neuroticism and worry � two important correlates of IU (Norton et al., 2005).

This indicates that the linkage between IU and symptom levels of complicated grief

and PTSD cannot be fully accounted for by the shared variance between IU, worry,

and neuroticism.

When we also controlled for the shared variance between symptom scores, IU

remained significantly associated with symptom levels of PTSD but not complicated

grief. Moreover, in our final regression analysis, PTSD symptom severity but not

complicated grief symptom severity emerged as a unique correlate of IU, apart from

worry. These latter findings suggest that negative beliefs about uncertainty and its

implications, and other manifestations of IU as experienced in the aftermath of the

death of a close relative have a more specific linkage with fear-based intrusive images,

avoidant responses, and hyperarousal that characterize bereavement-related PTSD

than with symptoms of separation distress that characterize complicated grief.

However, it is important to note that complicated grief and PTSD severity scores

were very strongly correlated. Conclusions based on the analyses in which the sharedvariance between these scores was controlled should therefore be drawn with

caution.

The present study has several other limitations that should be taken into account.

Firstly, the current sample was heterogeneous with respect to features of the loss such

as time since loss, cause of loss, and relationship to the deceased. Thus, future studies

are needed to examine the associations of IU with loss-related distress in specific

subgroups of bereaved people, such as people who recently lost a partner. Secondly,

the sample was composed of self-selected, predominantly relatively highly educated

people with Internet access, most of whom were female. This limits the general-

izability of the results. Thirdly, the cross-sectional design does not allow for any

conclusions to be drawn about the possible causal relationship between IU and loss-

related distress. In a related vein, because data were collected after the losses had

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occurred, it is uncertain to what extent IU was affected by the loss. Thus, it would be

interesting for future studies, designed to explore the causal role of IU in emotional

problems following loss, to include a pre-loss assessment of IU. Fifthly, the fact that

symptom measures of complicated grief and PTSD, and measures of IU, worry, andneuroticism were administered at two different waves of data collection is a

limitation of this study. Thus, for instance, we cannot preclude that differences in

state mood at the two moments that the questionnaires were completed influenced

the present study findings.

Notwithstanding these limitations, the current study adds to our knowledge of

factors associated with emotional distress following loss. More broadly, the present

findings complement earlier findings in showing that IU is specifically critical to

worry (Dugas et al., 2004; Koerner & Dugas, 2006) but that it may also be acognitive vulnerability factor for other anxiety disorders and symptoms (cf. Boelen &

Reijntjes, 2009; Holaway et al., 2006). At the very least, findings indicate that a more

comprehensive examination of the role of IU in emotional distress following loss is

warranted. If future studies show that IU is causally related to such distress, this

would have clinical implications. For instance, it would suggest that augmenting

people’s tolerance for the uncertainty that, in many instances, is inherent to the

situation that emerges when a loved one dies is a potentially fruitful intervention in

the treatment of bereaved individuals displaying difficulties successfully coping withtheir loss.

Acknowledgements

This research was supported by an Innovative Research Incentive Veni Grant (451-06-011)from the Netherlands Organization for Scientific Research (NWO) awarded to the author.Hans Pieterse is thanked for his help with the collection of data. Albert Reijntjes is thanked forhis helpful comments on earlier drafts of this paper.

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