Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief, posttraumatic stress, and depression after bereavement

Emotion regulation mediates the relation between intolerance of uncertainty and emotion difficulties: A longitudinal investigation

Intolerance of uncertainty has been proposed as a transdiagnostic factor in emotional disorders. Despite comprehensive empirical evidence demonstrating the association between intolerance of uncertainty and emotional disorders, the underlying mechanism remains elusive. Drawing on theoretical frameworks and empirical studies, the current study proposed that emotion regulation emerges as a potential mechanism. We explored the connections among intolerance of uncertainty, eight emotion regulation strategies (both adaptive and maladaptive), and emotional difficulties (specifically anxiety and depression) using a three-wave longitudinal approach (N = 341). Our findings revealed that heightened intolerance of uncertainty predicted increased anxiety but not depression over time. Greater intolerance of uncertainty significantly predicted elevated levels of maladaptive emotion regulation strategies including experiential avoidance, thought suppression, rumination, and reassurance-seeking. Adaptive strategies (i.e., mindfulness, cognitive reappraisal, problem-solving) predicted lower anxiety and/or depression whereas maladaptive emotion regulation strategy rumination predicted greater levels of anxiety and depression. Surprisingly, thought suppression predicted lower levels of anxiety and depression. More importantly, our analysis showed that both rumination and thought suppression served as significant mediators in the relationship between intolerance of uncertainty and both anxiety and depression. These results hold implications for future interventions, emphasising rumination and thought suppression as potential targets for interventions aimed at alleviating emotional difficulties in individuals with intolerance of uncertainty.

Multimodal assessment of the role of intolerance of uncertainty in fear acquisition and extinction

Personality traits linked to internalizing disorders influence the way we develop fears, but also how we regain a sense of safety. In the present study, we investigated the effect of intolerance of uncertainty (IU) on defensive responses using a differential fear conditioning protocol with an extinction phase. The conditioned stimulus was associated with an aversive sound (90 dB) in 75 % of the presentations during acquisition. A final sample of 176 participants completed the experiment. We measured self-reports of associative (expectancy of the unconditioned stimulus in acquisition) and evaluative learning (arousal and valence), and both physiological (skin conductance response) and electrocortical responses (steady-state visually evoked potentials, ssVEPs; late positive potentials, LPP) to the conditioned stimuli. Our results show that IU's impact is limited, with no effect in both acquisition and extinction. These findings emphasize the necessity of large samples in research on inter-individual differences and contribute to our understanding of how IU may or may not be involved in fear and safety learning processes considering multiple aspects of fear responding.

Examining worry and secondary stressors on grief severity using machine learning

BACKGROUND & OBJECTIVES

Worry and loss-related secondary stressors appear to be important correlates of problematic grief responses. However, the relative importance of these variables in the context of established correlates of grief responding, ranging from indicators of identity disruption and demographic characteristics of the bereaved to characteristics of the loss of quality of the relationship with the deceased, is unknown. Modeling the relative associations of these factors can be problematic, given the high degree of collinearity between these variables. This study used a machine learning approach to provide accurate estimations of the relative importance of these correlates for post-loss symptom severity.

METHODS AND RESULTS

A convenience sample of 428 bereaved people who had lost a parent, spouse, or child in the last 30 to 365 days completed an online survey. Random forest regression modeling examined the effects of worry and secondary stressors on symptom severity in the context of established correlates. Results indicated worry and the number of secondary stressors experienced were among the factors most strongly associated with severity of grief, depression, posttraumatic stress and problems functioning.

CONCLUSIONS

These results also provide insight into the relative importance of worry and secondary stressors affecting grief severity to guide future research.

The Psychological Health Symptoms of DACA Recipients: A Systematic Review at the Ten-Year Mark of the Program

The purpose of this systematic review was to identify the mental health symptoms endorsed by DACA recipients. This study included qualitative and quantitative original, peer-reviewed articles related to mental health or psychological state or wellbeing of DACA recipients. Articles were abstracted from PsychInfo, PubMed, and GoogleScholar. The results included a total of fifteen articles, which were divided into qualitative and quantitative findings. The qualitative articles had a common theme of endorsement of depressive symptoms and negative affect associated to changes in familial and financial responsibilities and living in a difficult sociopolitical climate in the United States. The quantitative articles identified lower odds or symptom severity of depression and other internalizing symptoms compared to undocumented individuals. This summary review was limited by the ample exclusion of access to health care studies among DACamented individuals, which could have provided a broader picture about the health and accessibility for DACA recipients. Despite the limitations, this review identifies DACA as a policy that allows this group to improve their social function and quality of life compared to undocumented individuals but still endorse high levels of negative affect related to perceived challenging sociopolitical atmospheres.

Protective Factors in the Context of Childhood Bereavement: Youth Gratitude, Future Orientation, and Purpose in Life

The objective of the study was to examine potential associations between positive youth development constructs (gratitude, future orientation, purpose in life) and psychological functioning (posttraumatic stress symptoms, depressive symptoms, maladaptive grief reactions) among bereaved youth and test whether these associations vary by age. A diverse sample of 197 clinic-referred bereaved youth (56.2% female; M = 12.36, SD = 3.18; 36.1% Hispanic, 23.7% White, 20.1% Black, 11.9% Multiracial, and 8.2% another race/ethnicity) completed self-report measures of psychological functioning and positive youth development constructs. Linear regression models indicated that gratitude and purpose were associated with lower posttraumatic stress and depressive symptoms among bereaved youth. Future orientation was associated with higher posttraumatic stress symptoms. Results were consistent across age. If replicated longitudinally, gratitude and purpose may be important protective factors against negative mental health outcomes in the aftermath of losing a loved one.

Pre-job loss grief reactions and work attachment among sick-listed employees: Introduction of the imminent Job Loss Scale

BACKGROUND

With this study, we aimed to explore the emotional experiences of sick-listed employees facing imminent job loss, as this emotional distress may hinder successful job search outcomes. The study had two objectives: (1) to develop and validate the Imminent Job Loss Scale (IJLS) for assessing pre-job loss grief reactions and (2) to examine its relationship to work attachment.

METHODS

Development of the 9-item IJLS was carried out using feedback from an expert panel, consisting of five academic experts in grief and labour, five re-integration specialists, and five sick-listed employees facing imminent job loss. The psychometric properties of the IJLS were evaluated, and its association with work attachment was examined using data from 200 sick-listed employees facing imminent job loss.

RESULTS

The IJLS demonstrated strong internal consistency and temporal stability, distinctiveness from depression and anxiety symptoms, and solid convergent validity. Work-centrality and organizational commitment were positively related to pre-job loss grief reactions, while work engagement and calling showed no significant associations.

CONCLUSION

This study provides valuable insights into pre-job loss grief reactions and shows the potential utility of the IJLS for screening and monitoring purposes. Understanding pre-job loss grief reactions can improve the re-integration and job prospects of sick-listed employees. In future research, explorations of these dynamics should continue to provide better support to sick-listed employees during this challenging period.

Transdiagnostic factors in symptoms of depression and post-traumatic stress: a systematic review

The current systematic review sought to identify quantitative empirical studies that focused on the transdiagnostic factors of intolerance of uncertainty, emotional dysregulation and rumination, and their relation with depression and post-traumatic stress disorder (PTSD). The overall research aim was to examine the relationship between these transdiagnostic factors and their relation with depression and PTSD symptoms. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Out of the 768 articles initially identified, 55 met the inclusion criteria for the current review. The results determined that intolerance of uncertainty is indirectly related to depression and PTSD symptoms, mainly through other factors including emotion dysregulation and rumination. Additionally, emotional dysregulation is a significant predictor of both depression and PTSD symptoms. Rumination is a robust factor related to depression and PTSD symptoms, this relationship was significant in cross-sectional and longitudinal studies. This review provides evidence on the transdiagnostic factors of intolerance of uncertainty, emotional dysregulation and rumination in the relationship with depression and PTSD symptoms.

Do perfectionists show negative, repetitive thoughts facing uncertain situations?

Perfectionism, intolerance of uncertainty and repetitive negative thinking are all psychological traits, which are treated as transdiagnostic phenomena for the development and the maintenance of psychopathology. The aim of the current work was to investigate the associations between repetitive negative thinking and the multidimensional aspects of perfectionism (perfectionistic strivings and perfectionistic concerns) and intolerance of uncertainty (prospective and inhibitory) in one model. Two studies were conducted in which participants (N1 = 227; N2 = 148) completed questionnaires in an online survey. The first study measured rumination and worry separately as repetitive negative thinking processes. The second study measured repetitive negative thinking as an underlying construct of rumination and worry using a single questionnaire. We applied hierarchical regression analyses and mediation analyses in both studies. The mediation analyses in both studies showed that inhibitory intolerance of uncertainty significantly partially mediated the relationship between perfectionistic concerns and repetitive negative thinking (as well as worry and rumination). Perfectionistic concerns seem to be the more crucial perfectionism aspect for transdiagnostic considerations, particularly in association with a heighten inhibitory intolerance of uncertainty and repetitive negative thinking. Both studies strongly affirm the necessity to use the multidimensional aspects of perfectionism and intolerance of uncertainty in psychological research.

Intolerance of uncertainty, posttraumatic stress, depression, and fears for the future among displaced refugees

INTRODUCTION

The vast majority of the 100 million forcibly displaced persons worldwide live in a state of prolonged uncertainty with limited resettlement prospects and access to resources. Little is known, however, regarding how refugees and asylum-seekers cope with this uncertainty.

METHODS

In this study, we investigated the longitudinal association between a measure of how people cope with uncertainty (intolerance of uncertainty (IU)), fears for the future, posttraumatic stress disorder (PTSD) symptoms and depression symptoms. A sample of 1,237 refugees displaced in Indonesia completed an online survey in Arabic, Farsi, Dari, Somali or English at two time-points six-months apart.

RESULTS

Results indicated that greater IU-inhibitory anxiety (IU-IA or impairment related to uncertainty) was associated with subsequent increases in PTSD and depression symptoms and fears for the future. Greater PTSD symptoms and fears for the future were associated with increases in IU-prospective anxiety (IU-PA or distress related to uncertainty), and greater depression symptoms were associated with increases in IU-IA.

DISCUSSION

These findings provide evidence for the mechanistic role of IU in psychological symptoms amongst displaced refugees. Results underscore the importance of policies to reduce uncertainty in displacement environments, and highlight IU as a potential intervention target to help refugees cope with protracted displacement.

Reciprocal Relations of Worry, Rumination, and Psychopathology Symptoms After Loss: A Prospective Cohort Study

Bereavement can precipitate symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder. Targeting repetitive negative thought (i.e., worry, rumination) in treatment may help reduce post-loss psychopathology. Yet, evidence on longitudinal associations of depressive rumination and worry with post-loss psychopathology symptoms has been mixed and the directions of effects are still unclear. Recently bereaved adults (78% female) completed questionnaires assessing depressive rumination (brooding), worry, and depression, prolonged grief and posttraumatic stress symptoms 11 times in 1.5 month intervals. We applied random-intercept cross-lagged panel models (RICLPMs) to examine reciprocal within-person associations between worry and psychopathology symptoms, between rumination and these symptoms, and between worry and rumination. Main findings were that worry showed reciprocal relationships with psychopathology symptoms (although worry did not consistently predict prolonged grief symptoms). Depressive rumination was predicted by psychopathology symptoms, but not vice versa. Worry showed reciprocal relations with depressive rumination. Findings suggest that worry may be part of a downward spiral, enhancing psychopathology symptoms following loss, whereas depressive rumination is solely a consequence of such symptoms.

No intolerance of errors: The effect of intolerance of uncertainty on performance monitoring revisited

Errors have been conceptualized as internal forms of threat that can cause harm in unpredictable ways. An index of error processing is the error-related negativity (ERN), an event-related potential reflecting variability in the sensitivity to errors. Prior work has shown the relationship between psychopathology symptoms and the ERN is unclear, and may be moderated by intolerance of uncertainty (IU), a trait that captures how people react to unpredictability. IU includes two subfactors of prospective IU (active seeking of predictability) and inhibitory IU (behavioral paralysis). In the present study, 188 undergraduates performed an Eriksen flanker task designed to elicit the ERN, while brain activity was recorded using electroencephalography (EEG). Participants completed the Intolerance of Uncertainty Scale, Short Form (IUS-12), and other measures of anxiety, depression and worry. Total IU explained 5 % of the variance in correct-response negativity (CRN), but was not associated with the ERN in our sample. In contrast to previous findings, the IU subfactors did not predict the ERN or post-error slowing (PES), nor did total IU and depression interact to predict the ERN. Exploratory analyses also showed that total IU did not moderate the relationship between trait anxiety and the ERN. Small samples may have previously exaggerated the links between self-reported IU and the ERN. As such, further high-powered replications are required to confirm if, and how, they are related.

The impact of psychological hardiness on intolerance of uncertainty in university students during the COVID-19 pandemic

The purpose of the study was to measure the impact of psychological hardiness on the intolerance of uncertainty (IOU) among university students during the coronavirus disease 2019 (COVID-19) pandemic. A cross-sectional correlational research design was used in the study, where participants were selected by convenience sampling. The data was collected from 1217 undergraduate students from a university in Turkey through web-based questionnaires. The Intolerance of Uncertainty Scale assessed data, including intolerance of uncertainty. In addition, the Personal Views Survey III-R was used to measure students' psychological hardiness. The results indicated that Turkish undergraduate students overall had high IOU and above-average psychological hardiness. Psychological hardiness was negatively correlated with IOU. Students losing a loved one because of COVID-19 had increased intolerance to uncertainty and lower psychological hardiness. Psychological hardiness was a powerful predictor of IOU. These findings show the need to implement hardiness-training programs for undergraduate students to increase their tolerance to uncertainty and reduce the effect of grief.

The Effects of Bereavement Time on the Relationship Between Coping Strategies and Psychological Distress

The purpose of this study was to investigate the relationship between bereaved individuals' coping patterns, mental health, and time post-loss. A questionnaire using the Coping with Bereavement Scale (CBS) and the Kessler Psychological Distress Scale (K6) was completed by 173 family members of individuals who died from cancer between August 2013 and March 2016. Confirmatory factor analysis revealed a three-factor solution for the CBS comprised of "life orientation," "avoidance," and "retaining ties" with the deceased. Scores on retaining ties were significantly but weakly correlated with K6 scores; however, the intensity of this relationship increased with more time post-bereavement, and individuals who retained strong ties with the deceased for two years or more demonstrated poorer mental health. Although retaining ties with the deceased might be an adaptive psychological process following bereavement, in this study, long-term persistence with that coping strategy was associated with greater overall psychological distress. Further research is needed to identify optimal coping methods to address evolving needs during the bereavement process.

Uncertain in the face of change: Lack of contingency shift awareness during extinction is associated with higher fear-potentiated startle and PTSD symptoms in children

Intolerance of uncertainty is a transdiagnostic risk factor for fear-related disorders and is associated with higher levels of anxiety in children and adolescents. It is unclear how uncertainty relates to development of psychopathology in children who have experienced trauma in early life. The present study used a fear-potentiated startle paradigm in children to examine associations between uncertainty (assessed as unawareness of a change in reinforcement during fear extinction) and symptoms of anxiety and posttraumatic stress disorder (PTSD), as well as startle potentiation to threat and safety cues. Results showed that unaware children had strong positive associations between trauma exposure and PTSD symptoms, whereas aware children did not. Uncertainty interacted with anxiety in that children who were both unaware and had higher anxiety displayed higher fear-potentiated startle to safety cues and did not show discrimination between threat and safety during fear conditioning. These results suggest that anxious children who persist in associating a threat cue with an aversive event during extinction, after repeated presentations of the no longer reinforced conditioned stimulus, may express psychophysiological phenotypes related to PTSD.

Shifting and intersecting needs: Parents' experiences during and following the withdrawal of life sustaining treatments in the paediatric intensive care unit

OBJECTIVES

To examine parents' perceptions of nursing care needs; including specific concerns, preferences and supportive actions for themselves and their dying child during and following the withdrawal of life support in the paediatric intensive care unit.

RESEARCH DESIGN

Qualitative description with content analysis.

SETTING

Interviews with eight parents of eight children who died in the paediatric intensive care unit 7-11 years prior.

MAIN OUTCOME MEASURES

Descriptive categories of parents' perceptions of end-of-life needs.

FINDINGS

Parents identified four shifting and intersecting categories of needs: To be together, To make sense of the child's evolving clinical care, To manage institutional, situational, and structural factors, and To navigate an array of emotions in a sterile context. Being closely connected with the child was highly important, but often intersected with other domains, requiring nurses' support. Parents' memories demonstrated persistent uncertainty about their child's end-of-life care that influenced their long-term grief.

CONCLUSIONS

Intersections between parent-identified care needs suggest potential mechanisms to strengthen nurses' care for dying children. Equipped with the knowledge that the parent-child bond often shapes parents' priorities; nurses should aim to facilitate connections amidst paediatric intensive care unit processes. Ongoing uncertainty in parents' adaptation to loss suggests that attention to instances when needs intersect can have a lasting impact on parents' grief.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.

Hyperreactivity to uncertainty is a key feature of subjective cognitive impairment

With an increasingly ageing global population, more people are presenting with concerns about their cognitive function, but not all have an underlying neurodegenerative diagnosis. Subjective cognitive impairment (SCI) is a common condition describing self-reported deficits in cognition without objective evidence of cognitive impairment. Many individuals with SCI suffer from depression and anxiety, which have been hypothesised to account for their cognitive complaints. Despite this association between SCI and affective features, the cognitive and brain mechanisms underlying SCI are poorly understood. Here, we show that people with SCI are hyperreactive to uncertainty and that this might be a key mechanism accounting for their affective burden. Twenty-seven individuals with SCI performed an information sampling task, where they could actively gather information prior to decisions. Across different conditions, SCI participants sampled faster and obtained more information than matched controls to resolve uncertainty. Remarkably, despite their ‘urgent’ sampling behaviour, SCI participants were able to maintain their efficiency. Hyperreactivity to uncertainty indexed by this sampling behaviour correlated with the severity of affective burden including depression and anxiety. Analysis of MRI resting functional connectivity revealed that SCI participants had stronger insular-hippocampal connectivity compared to controls, which also correlated with faster sampling. These results suggest that altered uncertainty processing is a key mechanism underlying the psycho-cognitive manifestations in SCI and implicate a specific brain network target for future treatment.

Intolerance of uncertainty prospectively predicts the transdiagnostic severity of emotional psychopathology: Evidence from a Veteran sample

Intolerance of uncertainty (IU) has been conceptualized as a transdiagnostic vulnerability for emotional psychopathology, but few studies have tested whether it prospectively predicts emotional psychopathology, and none have utilized transdiagnostic and clinician-rated outcomes. To fill this gap, the present study tested whether IU prospectively predicted the clinician-rated severity of transdiagnostic emotional psychopathology six months later in a treatment-seeking Veteran sample. Participants completed the Intolerance of Uncertainty 12-item scale (IUS-12) and the Structured Clinical Interview for the DSM-5 (SCID-5) at Time 1 and again six-months later (Time 2); assessed emotional disorders included both anxiety-related disorders (i.e., post-traumatic stress disorder, generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive compulsive disorder, specific phobia) and depressive conditions (i.e., major depressive disorder and persistent depressive disorder). Linear regression analyses revealed a bidirectional prospective relation between IU and emotional psychopathology, wherein higher Time 1 IUS-12 predicted greater Time 2 emotional disorder severity and greater Time 1 emotional disorder severity predicted higher Time 2 IUS-12. Follow-up analyses revealed that IU prospectively predicted the maintenance (but not the development) of anxiety-related issues, whereas prediction of Time 2 depression was nullified when controlling for Time 1 anxiety pathology. These findings implicate IU as a transdiagnostic vulnerability for emotional psychopathology and suggest the construct can be particularly useful as a treatment target and prognostic indicator for anxiety-related conditions.

COVID-19-Related Posttraumatic Stress Disorder Among Jordanian Nurses During the Pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak has been declared a pandemic and has affected both patients and health-care workers. This study was conducted to explore the extent of posttraumatic stress disorder (PTSD) experiences among nurses because of the COVID-19 pandemic in Jordan.

METHODS

This study used a cross-sectional study design with a convenience sampling approach. A sample of 259 participants completed the study questionnaires, including a socio-demographic questionnaire and the Posttraumatic Stress Disorder Checklist for DSM-5 between May and July 2020.

RESULTS

The prevalence of PTSD among the study participants was 37.1%. Most study participants who exhibited PTSD symptoms presented the lowest level of PTSD (17%). The results showed significant differences in overall COVID-19-related PTSD according to the participant's age (F = 14.750; P = 0.000), gender (F = 30.340; P = 0.000), level of education (F = 51.983; P = 0.000), years of experience (F = 52.33, P = 0.000), place of work (F = 19.593; P = 0.000), and working position (F = 11.597; P = 0.000), as determined by 1-way ANOVA.

CONCLUSIONS

Nurses must be qualified and accredited to cope with reported PTSD cases and their consequences in relation to COVID-19 outbreaks. A close collaboration with a multidisciplinary team is required to recognize, manage, and encourage safety literacy among health-care professionals and individuals diagnosed with or suspected of PTSD due to COVID-19 outbreaks or any other viral outbreaks.

Prolonged grief and posttraumatic stress disorder following the loss of a significant other: An investigation of cognitive and behavioural differences

BACKGROUND

Cognitive behavioural correlates to bereavement-related mental health problems such a Prolonged Grief Disorder (PGD) and Posttraumatic Stress Disorder (PTSD) are of theoretical and clinical importance.

METHODS

Individuals bereaved at least six months (N = 647) completed measures of loss-related cognitions and behaviours (i.e., loss-related memory characteristics, negative appraisals, coping strategies, grief resilience, and perceived social disconnection) and measures of PGD and PTSD symptoms. Individuals were assigned to one of four groups depending on probable clinical diagnoses (No-PGD/PTSD, PTSD, PGD, PGD+PTSD).

RESULTS

Results indicated that higher loss-related memory characteristics and lower grief resilience increased the likelihood of a clinical problem. The PGD and PGD+PTSD groups reported significantly higher loss-related memory characteristics and appraisals compared to the PTSD group. Social disconnection increased the likelihood of comorbid PGD+PTSD in comparison to any other group.

CONCLUSIONS

Results indicate cognitive differences between loss-related cognitions, memory characteristics and coping strategies between PGD and PTSD, and points to distinct cognitive correlates to psychopathology following loss.

Emotion Regulatory Strategies in Complicated Grief: A Systematic Review

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence, and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsycInfo, Web of Science, and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7,715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.

A framework of meaning attribution following loss

The loss of a loved one causes the world and the place of the bereaved survivor in it to change irreversibly. A key aspect of the grieving process is the integration of the loss in the bereaved survivor's life story, identity change, and a new future orientation through meaning attribution. Meaning attribution can have favourable or unfavourable effects on the grieving process and hence determines the extent to which a loss disrupts the bereaved survivor's functioning. A framework of meaning attribution after loss is presented, comprising 17 determinants that fall into five categories: event-related, cultural, social, individual and relational determinants. Each determinant may lead to both positive and negative meanings, thereby facilitating or complicating the grieving process. The framework of meaning attribution highlights the importance of an integrated network for mental health care, spiritual care, and end-of-life care in the prevention and treatment of traumatic grief. It also emphasizes the support from relatives, collective rituals, cultural views, legal settlements, and other societal factors that may foster or impede adaptation to loss. The framework of meaning attribution informs research across a range of research themes, including specialist care for traumatic grief, a culturally sensitive care network for traumatic grief, and improving care for ambiguous loss in a global context.

Psychological effects of nurses and midwives due to COVID-19 outbreak: The case of Turkey

PURPOSE

The study was carried out to determine the psychological impact levels of nurses and midwives due to the COVID-19 outbreak.

METHODS

The research is planned in a descriptive type. Nurses and midwives working in any health institution in Turkey constituted the population of the research. The questionnaire form of the study was shared on social media tools between 01 and 14 April 2020 and a total of 758 nurses and midwives were included in the study sample. Personal Information Form, State-Trait Anxiety Inventory and Intolerance of Uncertainty Scale were used as data collection tools.

RESULTS

Participants who attended the study were 56.9% of nurses and 43.1% of midwives. Approximately half of the nurses and midwives (48.8%) participating in our study contacted the patient with suspected COVID-19, and 29.8% provided care to the patient diagnosed with COVID-19. Nurses and midwives were scored 52.75 ± 9.80 for State Anxiety, 44.87 ± 7.92 for Trait Anxiety Inventory and 35.16 ± 9.42 for Intolerance of Uncertainty Scale. It has been determined that 54.5% of nurses and midwives have been making their lives worse since the outbreak started, 62.4% had difficulties in dealing with the uncertain situation in the outbreak, 42.6% wanted psychological support and 11.8% had alienated from their profession. It was determined that there was a difference between scale scores and difficulties in work, family and private life due to COVID-19.

CONCLUSION

As a result, it is seen that the midwives and nurses in our country have high psychological effects due to the COVID-19 outbreak.

Symptoms of prolonged grief, posttraumatic stress, and depression in recently bereaved people: symptom profiles, predictive value, and cognitive behavioural correlates

PURPOSE

Prior latent class analyses (LCA) have focused on people who were bereaved more than 6 months earlier. Research has yet to examine patterns and correlates of emotional responses in the first few months of bereavement. We examined whether subgroups could be identified among very recently (≤ 6 months) bereaved adults, based on their endorsement of symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Associations of class membership with overall disturbed grief, PTSD, and depression-assessed concurrently and at 6 months follow-up-were examined. Furthermore, we examined differences between classes regarding socio-demographics, loss-related, and cognitive behavioural variables.

METHODS

PGD, PTSD, and depression self-report data from 322 Dutch individuals bereaved ≤ 6 months earlier were subjected to LCA; N = 159 completed the follow-up assessment. Correlates of class membership were examined.

RESULTS

Three classes were identified: a low symptom class (N = 114; 35.4%), a predominantly PGD class (N = 96; 29.8%), and a high symptom class (N = 112; 34.8%). PGD, PTSD, and depression scores (assessed concurrently and at 6 months follow-up) differed significantly between classes, such that low symptom class < predominantly PGD class < high symptom class. Being a woman, younger, more recently bereaved, experiencing deaths of a partner/child and unnatural losses, plus maladaptive cognitions and avoidance behaviours were associated with membership of the pervasive symptom classes.

CONCLUSION

In the first 6 months of bereavement, meaningful subgroups of bereaved people can be distinguished, which highlights the relevance of early detection of people with elevated bereavement-related distress and offering them preventive interventions that foster adaptation to loss.

How thinking hurts: Rumination, worry, and avoidance processes in adjustment to bereavement

Repetitive negative thought plays an important role in the maintenance of mental health problems following bereavement. To date, bereavement researchers have primarily focused on rumination (i.e., repetitive thought about negative events and/or negative emotions), yet the interest in worry (i.e., repetitive thought about uncertain future events) is increasing. Both cognitive processes potentially lead to poorer adaptation to bereavement by contributing to loss‐related avoidance and behavioural avoidance of activities. The current study aims to establish the differential associations of rumination and worry with symptoms of depression and prolonged grief and clarify if avoidance processes mediate the associations of rumination and worry with symptom levels. Four hundred seventy‐four recently bereaved adults (82% female) filled out questionnaires assessing rumination, worry, loss‐related and behavioural avoidance, and depression and prolonged grief symptoms. Rumination and worry were both uniquely associated with depression and prolonged grief symptoms. Compared with worry, rumination related more strongly to prolonged grief symptoms, whereas correlations of both cognitive styles with depression symptoms did not differ. Loss‐related avoidance and behavioural avoidance partially mediated the associations of rumination and worry with prolonged grief symptoms. Behavioural avoidance partially mediated the associations of rumination and worry with depression symptoms. Findings suggest that exposure and behavioural activation may be effective interventions to reduce repetitive thinking and psychopathology after bereavement.

Factorial validity and measurement invariance of the uncertainty response scale

This study presents the adaptation of the Uncertainty Response Scale (Greco & Roger, Pers. Individ. Differ, 31:519-534, 2001) to Portuguese. This instrument was administered to a non-clinical community sample composed of 1596 students and professionals, allowing a thorough validity and invariance analysis by randomly dividing participants into three subsamples to perform: an exploratory factor analysis (sample one: N = 512); a preliminary confirmatory factor analysis to identify the final solution for the scale (sample two: N = 543); and the confirmatory factor analysis (sample three: N = 541). Samples two and three were also used for multi-group analysis to assess measurement invariance, invariance across gender, sociocultural levels, and students versus active professionals. Results showed the scale reflects the original factorial structure, as well as good internal consistency and overall good psychometric qualities. Invariance results across groups reached structural invariance which provides a confident invariance measurement for this scale, while invariance across gender and sociocultural levels reached metric invariance. Accordingly, differences between these groups were explored, by comparing means with multi-group analysis to establish the scale's sensitivity toward social vulnerability, by demonstrating the existence of statistically significant differences regarding gender and sociocultural levels on how individuals cope with uncertainty, specifically in terms of emotional strategies, as a self-defeating strategy. Thus, females scored higher on emotional uncertainty, as well as low sociocultural levels, compared with higher ones. Therefore, it is proposed that this scale could be a sound alternative to explore strategies for coping with uncertainty, when considering social, economic, or other environmental circumstances that may affect them.

Demographic and cognitive risk factors for police mental disorder symptoms

The current study was designed to assess whether cognitive risk factors (i.e. anxiety sensitivity (AS), intolerance of uncertainty (IU)) explained variance in mental disorder symptoms in Canadian police officers beyond variance explained by demographic variables (i.e. sex, marital status, education, years of service). Police participants (708 men; 271 women) completed measures assessing posttraumatic stress disorder, panic disorder, social anxiety disorder, major depressive disorder, generalized anxiety disorder, IU and AS. Multivariate analysis of variance demonstrated that only main effects of sex were significant for all symptom variables, except SAD. Hierarchical multiple regressions demonstrated that AS and IU accounted for greater variance than sex on all mental disorder symptom measures, which suggests that cognitive risk factors explain more variance in mental disorder symptoms than sex. Efforts to reduce AS and IU may be beneficial for improving police mental health.

The impact of methodological and measurement factors on transdiagnostic associations with intolerance of uncertainty: A meta-analysis

Intolerance of uncertainty is a dispositional trait associated with a range of psychological disorders, but the influence of methodological factors on theses associations remains unknown. The first aim of this meta-analysis was to quantify the strengths of the association between IU and symptoms of generalised anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, obsessive compulsive disorder, depression, and eating disorders. The second aim was to assess the influence of methodological factors on these relationships, including clinical (vs. non-clinical) status, age group, sex, IU measure, and symptom measure. We extracted 181 studies (N participants = 52,402) reporting 335 independent effect sizes (Pearson's r). Overall, there was a moderate association between IU and symptoms (r = 0.51, 95% CI = 0.50-0.52), although heterogeneity was high (I² = 83.50, p < .001). Some small but significant moderator effects emerged between and within disorders. Effect sizes were not impacted by sample size. The results indicate that IU has robust, moderate associations with a range of disorder symptoms, providing definitive evidence for the transdiagnostic nature of IU.

Intolerance of uncertainty and DSM-5 PTSD symptoms: Associations among a treatment seeking veteran sample

Intolerance of uncertainty (IU), defined as an inability to tolerate the unpleasant response triggered by the observed absence of information, has received increased empirical attention in recent years. The contribution of this cognitive behavioral construct to the etiology and maintenance of various anxiety disorders has become increasingly recognized. However, the relationship between IU and other affective disorders, including posttraumatic stress disorder (PTSD), remains largely unexplored. The current study sought to examine the relationship between IU and overall PTSD symptom and cluster severity using an outpatient sample of veterans (N = 116) assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) PTSD symptom structure. Results revealed that IU was significantly associated with overall PTSD symptom severity, above and beyond relevant covariates. Further, IU was significantly associated with the PTSD avoidance and hyperarousal clusters. Prospective IU, rather than inhibitory IU, accounted for these unique associations. These findings add to a growing body of literature establishing IU as a transdiagnostic risk factor and point to the importance of future research on the role of IU in contributing to and/or maintaining PTSD symptoms.

Enhancing Inhibitory Learning: The Utility of Variability in Exposure

Exposure therapy has strong empirical support as a treatment for anxiety and related disorders, yet not all participants see clinically meaningful reduction in symptoms, and some experience return of fear. In this review, we examine the theoretical models of exposure therapy, from early precursors to the contemporary inhibitory learning model. The inhibitory learning model is applied to examine one potential method of improving outcomes in exposure therapy: increasing variability in the progression of the exposure hierarchy. We explore mechanisms that support the use of variability in exposure, including the violation of expectancies to enhance learning. In addition, the role of intolerance of uncertainty in anxiety is examined; variable exposure therapy could target this transdiagnostic mechanism in anxiety and related disorders. Suggestions for future research are then offered.

A pilot randomised controlled trial of metacognitive therapy for prolonged grief

OBJECTIVES

Prolonged grief disorder is associated with significant distress and impairment and thus efforts to improve treatments are essential. The present pilot study tested the efficacy and feasibility of group Metacognitive Grief Therapy (MCGT) designed specifically for prolonged grief symptomatology to reduce the psychological distress and impaired function resulting from bereavement.

DESIGN/PARTICIPANTS

Twenty-two bereaved adult participants with prolonged grief symptomatology were randomised to a wait-list control (n=10) or an intervention condition (n=12) with a 3-month and 6-month follow-up. The wait-list control group was offered treatment after the post-test assessment.

INTERVENTION

Participants attended six group MCGT sessions that ran for 2 hours per week.

OUTCOME MEASURES

A primary outcome measure of prolonged grief symptomatology and secondary outcome measures of depression, anxiety, rumination, metacognitive beliefs and quality of life were taken pretreatment and post-treatment for both groups and at the 3-month and 6-month follow-up for the intervention group. A Generalised Linear Mixed Model was used to assess treatment efficacy.

RESULTS

Post-treatment intent-to-treat analyses showed MCGT reduced prolonged grief symptomatology (Cohen's d=1.7), depression (d=1.3), anxiety (d=0.8), stress (d=1.0), rumination (d=0.9) and increased quality of life (d=0.6), and these effects were maintained at the 3-month and 6-month follow-ups. No prepost between-group differences were found in metacognitive beliefs. However, a large significant effect was identified at the 3-month and 6-month follow-ups (d=1.0).

CONCLUSION

The results show promise for the utility of group MCGT for reducing psychological distress and promoting quality of life. Additionally, the results underscore the need for a full randomised controlled trial of group MCGT, which may be an important addition to the treatment armamentarium available to support people with prolonged grief.

TRIAL REGISTRATION NUMBER

ACTRN12613001270707; Results. ORIGINAL PROTOCOL: BMJ Open 2015;5:e007221. doi:10.1136/bmjopen-2014-007221.

Depression and Intolerance of Uncertainty: Relations between Uncertainty Subfactors and Depression Dimensions

Depression is often modeled as a unidimensional construct despite evidence for distinct symptom dimensions (i.e., cognitive, affective, and somatic symptoms). Intolerance of uncertainty (IU; a cognitive bias that increases distress in uncertain situations) is a risk factor implicated in the development of depression. However, it is unclear how IU lower-order dimensions (i.e., inhibitory IU, the fear of future unpredictable events; prospective IU, avoidance due to fear of uncertain events) relate to depressive symptoms. The current study used confirmatory factor analysis and structural equation modeling to examine the relations between depressive symptoms and lower-order dimensions of IU in a sample of 374 adults (M age = 35.5, 54.3% female) with elevated psychopathology (89.2% meeting criteria for at least one DSM-5 diagnosis, 25.6% primary depressive disorder). A two-factor model of depression, composed of Cognitive and Affective/Somatic factors, provided superior model fit compared to one- and three-factor solutions. A bifactor model of IU, composed of a general IU factor and specific Inhibitory IU and Prospective IU factors, provided superior model fit compared to one- and two-factor solutions. The general IU factor related to both Cognitive and Affective/Somatic factors. Inhibitory IU related to the Cognitive factor, but not the Affective/Somatic factor. Prospective IU was not related to Cognitive or Affective/Somatic factors. These findings elucidate the relations between IU and depression symptoms and have important theoretical implications regarding the etiology of depressive symptoms. In particular, inhibitory IU may be a novel target for intervention efforts in individuals presenting with depressive symptoms.

Anxiety sensitivity cognitive concerns drive the relation between anxiety sensitivity and symptoms of depression

Depression is typically treated as a homogeneous construct despite evidence for distinct cognitive, affective, and somatic symptom dimensions. Anxiety sensitivity (AS; the fear of consequences of anxiety symptoms) is a cognitive risk factor implicated in the development of depressive symptoms. However, it is unclear how lower order AS dimensions (i.e. physical, cognitive, and social concerns) relate to depressive symptom factors. Confirmatory factor analysis, followed by structural equation modeling, were conducted to examine the factor structure of depression and to then examine the relations between these factors and the lower order factors of AS. This study was conducted in a sample of 374 adults (M age = 35.5, 54.3% female) with elevated levels of psychopathology (89.2% meeting criteria for at least one DSM-5 diagnosis, 25.6% primary depressive disorder). In this study a two-factor model of depression, composed of Cognitive and Affective/Somatic factors, was superior to one- and three-factor solutions. AS cognitive concerns were related to both cognitive and affective/somatic symptoms of depression. Neither of the other AS dimensions was related to depression symptom dimensions. These findings provide a better understanding of the relations between AS and depression symptoms.

Exploratory study of metacognitive beliefs about coping processes in prolonged grief symptomatology

Despite research examining the role of metacognitive beliefs about coping processes in maintaining psychological disorders, to date, no studies have explored their role in the maintenance of prolonged grief. Twelve semistructured interviews were conducted with bereavement specialists and bereaved people with elevated grief to identify metacognitive beliefs about coping processes relevant to prolonged grief. Analysis revealed several metacognitive beliefs potentially driving maladaptive coping processes used by people with prolonged grief symptomatology. Findings may underpin the development of interventions that aim to modify unhelpful metacognitive beliefs that perpetuate maladaptive coping processes.

Lower-order anxiety sensitivity and intolerance of uncertainty dimensions operate as specific vulnerabilities for social anxiety and depression within a hierarchical model

Within a hierarchical framework for depressive and anxiety disorders, negative affect (NA) is posited to be indirectly related to social anxiety and depression through cognitive vulnerabilities, including intolerance of uncertainty (IU) and anxiety sensitivity (AS). However, few prior studies have considered whether the lower-order dimensions of IU (i.e., prospective and inhibitory IU) and AS (i.e., physical, cognitive, and social concerns) better explain the indirect relation between NA and social anxiety and depression. The indirect relations between NA and social anxiety and depression through these cognitive vulnerabilities were examined using structural equation modeling in a clinical sample (N=298). NA and social anxiety symptoms were indirectly related through AS social concerns and inhibitory IU, although a direct effect of NA was also found. Only AS social concerns explained the relation between NA and a social anxiety disorder diagnosis. AS cognitive concerns was the only cognitive vulnerability factor to indirectly explain the relation between NA and depressive symptoms, although a direct effect of NA was also found. These findings suggest that the lower-order dimensions of AS and IU demonstrate more specific and less transdiagnostic associations with social anxiety and depression.

Conflict-related trauma and bereavement: exploring differential symptom profiles of prolonged grief and posttraumatic stress disorder

BACKGROUND

Exposure to trauma and bereavement is common in conflict-affected regions. Previous research suggests considerable heterogeneity in responses to trauma and loss with varying symptom representations. The purpose of the current study was to (1) identify classes of prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD) symptom profiles among individuals who were exposed to both trauma and loss due to the Colombian armed conflict and (2) to examine whether sociodemographic, loss and trauma-related characteristics could predict class membership.

METHODS

Three hundred eight victims of internal displacement who had experienced trauma and loss were assessed through measures of PGD (PG-13), PTSD (PCL-C), and social support (DUKE-UNC). Latent class analysis (LCA) was performed to analyze differential profiles by symptoms of PGD and PTSD and multinomial logistic regression was used to analyze predictors of class membership.

RESULTS

LCA revealed a four-class solution: a resilient class (23.6%), a PTSD-class (23.3%), a predominately PGD class (25.3%) and a high distress-class with overall high values of PGD and PTSD (27.8%). Relative to the resilient class, membership to the PGD class was predicted by the loss of a close family member and the exposure to a higher number of assaultive traumatic events, whereas membership to the PTSD class was predicted by the perception of less social support. Compared to the resilient class, participants in the high distress-class were more likely to be female, to have lost a close relative, experienced more accidental and assaultive traumatic events, and perceived less social support.

DISCUSSION

Specific symptom profiles emerged following exposure to trauma and loss within the context of the Colombian armed conflict. Profiles were associated with distinct types of traumatic experiences, the degree of closeness to the person lost, the amount of social support perceived, and gender. The results have implications for identifying distressed subgroups and informing interventions in accordance with the patient's symptom profile.

Intolerance of uncertainty and post-traumatic stress symptoms: An investigation within a treatment seeking trauma-exposed sample

BACKGROUND

Intolerance of uncertainty (IU) has been associated with post-traumatic stress symptoms (PTSS) in the literature. However, no research to date has investigated the relationship between IU and PTSS within a clinical trauma-exposed sample, which is an important next step in the literature and crucial for the generalizability of these findings. Therefore, the current study hypothesized that IU would be related to increased PTSS within a clinical sample of trauma-exposed individuals. Further, we hypothesized that IU would be related to elevated PTSS after accounting for anxiety sensitivity (AS) and negative affect (NA), two known correlates of PTSS. Finally, we examined the relations between IU and the PTSS clusters (i.e., avoidance, emotional numbing, hyperarousal, and re-experiencing) while covarying for AS and NA.

METHODS

Participants included community adults (n=126) presenting at an outpatient clinic. All participants had previously experienced a traumatic event as defined by the DSM-5 PTSD Criterion A.

METHODS

Results revealed that IU was significantly associated with increased PTSS above and beyond AS and NA. Further, results indicated that IU was significantly related to the avoidance, hyperarousal, and emotional numbing PTSS clusters, even after covarying for AS and NA. IU was not significantly associated with the PTSS re-experiencing cluster once AS and NA were taken into account.

CONCLUSIONS

Our results expand upon the extant literature by demonstrating that IU is associated with PTSS above and beyond AS and NA within a clinical trauma-exposed sample. These findings are discussed in terms of promising directions for future research and treatment strategies.

Intolerance of uncertainty in emotional disorders: What uncertainties remain?

The current paper presents a future research agenda for intolerance of uncertainty (IU), which is a transdiagnostic risk and maintaining factor for emotional disorders. In light of the accumulating interest and promising research on IU, it is timely to emphasize the theoretical and therapeutic significance of IU, as well as to highlight what remains unknown about IU across areas such as development, assessment, behavior, threat and risk, and relationships to cognitive vulnerability factors and emotional disorders. The present paper was designed to provide a synthesis of what is known and unknown about IU, and, in doing so, proposes broad and novel directions for future research to address the remaining uncertainties in the literature.

The wonder and angst of exploring the unknown: Introduction to the special issue on intolerance of uncertainty

Interest in the relationship between intolerance of uncertainty (IU) and emotional disorders has rapidly increased over the last decade. Early theory and research focused on the relationship between IU and generalized anxiety disorder in particular; but, the roles that IU and the underlying 'fear of the unknown' play in the development, maintenance, and treatment of a broad array of emotional disorders have been explored more recently. This introduction provides a brief overview of the contributions to the special issue, which (a) summarize our current state of knowledge, (b) describe innovative methods for assessing and increasing our understanding IU within the context of various emotions and emotional disorders, (c) investigate associations between IU and therapeutic change, and (d) propose future research directions.

Fear of the unknown: One fear to rule them all?

The current review and synthesis was designed to provocatively develop and evaluate the proposition that "fear of the unknown may be a, or possibly the, fundamental fear" (Carleton, 2016) underlying anxiety and therein neuroticism. Identifying fundamental transdiagnostic elements is a priority for clinical theory and practice. Historical criteria for identifying fundamental components of anxiety are described and revised criteria are offered. The revised criteria are based on logical rhetorical arguments using a constituent reductionist postpositivist approach supported by the available empirical data. The revised criteria are then used to assess several fears posited as fundamental, including fear of the unknown. The review and synthesis concludes with brief recommendations for future theoretical discourse as well as clinical and non-clinical research.