Volume 24, Issue 4 (Winter 2019)                   IJPCP 2019, 24(4): 400-415 | Back to browse issues page


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Abdolpour G, Nasiri M, Mafakheri M, Mansouri K, Abdi R. Structural Equation Modeling of Intolerance of Uncertainty and Symptoms of Depression and General Anxiety Disorder: Investigation of the Mediating Role of Rumination. IJPCP 2019; 24 (4) :400-415
URL: http://ijpcp.iums.ac.ir/article-1-2822-en.html
1- PhD. in Clinical Psychology, Department of Psychology, Faculty of Humanities, University of Shahed, Tehran, Iran. , g.marand@yahoo.com
2- PhD. in Health Psychology, Department of Clinical Psychology, Faculty of Psychology and Education, University of Kharazmi, Tehran, Iran.
3- MSc. in Psychology, Department of Clinical Psychology, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran.
4- PhD. in Psychology, Department of Psychology, Faculty of Psychology and Education, Azarbaijan Shahid Madani University, Tabriz, Iran.
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Extended Abstract
1. Introduction

Intolerance of uncertainty significantly contributes to the experience of anxiety in general anxiety and other anxiety disorders, including obsessive-compulsive disorder [9, 10] and mood disorders [11, 12]. De Jong-Meyer, Beck and Riede [17] in their findings reported that individuals with higher intolerance of uncertainty have greater worry and rumination. In other words, the relationship between Intolerance of Uncertainty (IU), worry and rumination is a causal relationship. Most research in this field has been conducted on patients with anxiety (especially general anxiety disorder). For example, studies have indicated that uncertainty is the key in the explanation of concern as the main feature of the general anxiety disorder [27-29]. However, very few studies have examined IU between mood disorders. Because of the similarities and common factors between generalized anxiety disorder and depression, the question is whether the IU is also associated with depression or not. However, this has attracted a relatively less empirical interest in depression. 
Spasojevic´ and Alloy [36] postulated rumination as a mediator between cognitive risk factors/vulnerabilities and negative psychological outcomes (e.g. depression). Spasojevic´ and Alloy indicated that people with cognitive risk factors/vulnerabilities for depression (e.g. IU, self-criticism) are likely to consistently engage in rumination to cope with their negative mood. Thus, these authors conceptualized rumination as the underlying link (i.e. mediator) between cognitive vulnerability (e.g. IU) and adverse psychological outcomes. Accordingly, the purpose of this study is to present a hypothetical model and test it through Structural Equation Modeling (SEM) approach.

2. Method
The present study is a fundamental type and of a descriptive-correlational type in terms of data collection. Considering the minimum sample size required when the variables of the model (in the hypothesized model of the present study, 13 variables) ranges from 10 to 15, the sample size should be between 200 and 400 [37]. Therefore, the sample size of this study was equal to 250 subjects. To choose the subjects, by cluster sampling method, four colleges (School of Medicine, School of Paramedicine, School of Nursing and Midwifery, School of Public Health) were randomly selected. Then from each college, a number of students were randomly selected to include them in the research. 
To test the research hypotheses, the collected data were analyzed using SPSS V. 22 and LISREL 8.85 [42]. The fitness of the hypothesized model was assessed using SEM method. The data analysis was performed using the two-step approach of Anderson and Gerbing [43] as follows: in the first step, Confirmatory Factor Analysis (CFA) was used to assess the fitness of the measurement model, and in the second step, SEM was employed to assess the hypothesized structural model. 

3. Results
Table 1 presents the matrix of correlation coefficients between the variables of the research. According to the Table 1, the correlations are significant (0.549≥r≥0.357). The measurement model specifies the relationship between the observed and latent variables. The evaluation of the model was done using CFA method. The fit indices of the measurement
model (Table 2) presents a satisfactory fitness for this model. Therefore, the observed variables are capable of operating the latent variables.

 


 


 


 
In addition, assessing the structural model via the SEM method revealed that all fit indices of the hypothesized model were within the appropriate fitness range. Table 2 presents the fit indices for this model. Figure 1 depicts the hypothetical structural model with its standard coefficients. As seen in Figure 1, intolerance of uncertainty as an exogenous variable affects the rumination with a standard coefficient of 0.50. In addition, rumination affects general anxiety disorder and depression with standard coefficients of 0.72, 0.49, respectively. In the current study, the Bootstrap test was employed to evaluate the intermediate relationships. In this method, if the upper and lower limits of this test are either positive or negative, and zero is not between these two limits, then the indirect causal path will be significant. Table 3 presents the results of this test.

4. Discussion
The purpose of this study was to investigate the mediating role of rumination in the relationship between intolerance of uncertainty with symptoms of depression and general anxiety. Structural relations between the variables of the study indicate a good fit of the hypothesized model. To explain these findings, it can be said that those who have a lot of rumination, are susceptible [21] to obscure events, pessimistic forecasts and thoughts [48]. Rumination may maintain or increase the level of uncertainty. In addition, individual mental retardation, unsolved problems, and higher level of uncertainty can persist because rumination disrupts problem solving. Therefore, rumination may increase the link between uncertainty and anxiety intolerance by reinforcing and increasing distress related to uncertainty. 
Theoretically, the results of this research provide a supportive framework for Spasovich and Alvoy’s conceptual framework of rumination as interface between cognitive vulnerability and negative implications. This effect of rumination as a mediator indicates that people with a high level of uncertainty intolerance tend to chew on disturbances and disorders that worsen symptoms of anxiety and depression. In this study, uncertainty intolerance may lead to negative consequences (such as depression, anxiety) through passive 

 


 
concentration of rumination on negative experiences, which instead of active management, prolongs the stress associated with uncertainty intolerance. Perhaps, people with uncertain intolerance think that rumination will help them to better understand their feelings, gain insights and find solutions to the unknown situations they encounter.

Ethical Considerations
Compliance with ethical guidelines

All ethical principles were considered in this article. The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information; Moreover, They were allowed to leave the study whenever they wish, and if desired, the results of the research would be available to them.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contributions
All authors contributed in preparing this article.

Conflict of interest
The authors declare no conflict of interest.



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Type of Study: Original Research | Subject: Psychiatry and Psychology
Received: 2018/03/4 | Accepted: 2018/08/7 | Published: 2020/03/10

References
1. Sadock BJ, Sadock VA. Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2011.
2. Shihata S, McEvoy PM, Mullan BA. Pathways from uncertainty to anxiety: An evaluation of a hierarchical model of trait and disorder-specific intolerance of uncertainty on anxiety disorder symptoms. Journal of Anxiety Disorders. 2017; 45:72-9. [DOI: 10.1016/j.janxdis.2016.12.001] [PMID] [DOI:10.1016/j.janxdis.2016.12.001]
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders (DSM-5). Washington: American Psychiatric Association; 2013.
4. Kessler R, Walters E, Wittchen HU. Epidemiology. In: Heimberg RG, Turk CL, Mennin DS, editors. Generalized Anxiety Disorder: Advances in Research and Practice. New York: Guilford Press; 2004.
5. Ehsanmanesh M. [Epidemiology of mental disorders in Iran (Persian)]. Iranian Journal of Psychiatry & Clinical Psychology. 2001; 6(4):54-70.
6. Omidi A, Tabatabai A, Sazvar A, Akkashe G. [Epidemiology of mental disorders in urbanized areas of Natanz (Persian)]. Iranian Journal of Psychiatry & Clinical Psychology. 2003; 8(4):32-8.
7. Brain C. Advance psychology: Application, issues and perspective. Cheltenham: Nelson Thorenes; 2002.
8. Al Hamzawi AO, Bruffaerts R, Bromet EJ, AlKhafaji AM, Kessler RC. The epidemiology of major depressive episode in the Iraqi general population. PLOS One. 2015; 10(7):e0131937. [DOI:10.1371/journal.pone.0131937] [PMID] [PMCID]
9. Boelen PA, Reijntjes A. Intolerance of uncertainty and social anxiety. Journal of Anxiety Disorders. 2009; 23(1):130-5. [DOI:10.1016/j.janxdis.2008.04.007] [PMID]
10. Agheli F, Hasanzadeh R, Ghasemian D. [Compare of intolerance of uncertainty among obsessive-compulsive disorder, generalized anxiety disorder and healthy subjects (Persian)]. Journal of Novel Applied Sciences. 2013; 2(2):896-9.
11. Buhr K, Dugas MJ. Investigating the construct validity of intolerance of uncertainty and its unique relationship with worry. Journal of Anxiety Disorders. 2006; 20(2):222-36. [DOI:10.1016/j.janxdis.2004.12.004] [PMID]
12. Dugas MJ, Robichaud M. Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice. New York: Routledge; 2007.
13. Freeston MH, Rhéaume J, Letarte H, Dugas MJ, Ladouceur R. Why do people worry? Personality and Individual Differences. 1994; 17(6):791-802. [DOI:10.1016/0191-8869(94)90048-5] [DOI:10.1016/0191-8869(94)90048-5]
14. Holaway RM, Heimberg RG, Coles ME. A comparison of intolerance of uncertainty in analogue obsessive-compulsive disorder and generalized anxiety disorder. Journal of Anxiety Disorders. 2006; 20(2):158-74. [DOI:10.1016/j.janxdis.2005.01.002] [PMID]
15. Dugas MJ, Buhr K, Ladouceur R. The role of intolerance of uncertainty in the etiology and maintenance of generalized anxiety disorder. In: Heimberg RG, Turk CL, Mennin DS, editors. Generalized Anxiety Disorder: Advances in Research and Practice. New York: Guilford Press; 2003. [PMCID]
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17. de Jong Meyer R, Beck B, Riede K. Relationships between rumination, worry, intolerance of uncertainty and metacognitive beliefs. Personality and Individual Differences. 2009; 46(4):547-51. [DOI:10.1016/j.paid.2008.12.010] [DOI:10.1016/j.paid.2008.12.010]
18. Ward A, Lyubomirsky S, Sousa L, Nolen Hoeksema S. Can't quite commit: Rumination and uncertainty. Personality and Social Psychology Bulletin. 2003; 29(1):96-107. [DOI:10.1177/0146167202238375] [DOI:10.1177/0146167202238375]
19. Hartley S, Haddock G, e Sa DV, Emsley R, Barrowclough C. An experience sampling study of worry and rumination in psychosis. Psychological Medicine. 2014; 44(8):1605-14. [DOI:10.1017/S0033291713002080] [PMID] [DOI:10.1017/S0033291713002080]
20. Wolkenstein L, Zwick JC, Hautzinger M, Joormann J. Cognitive emotion regulation in euthymic bipolar disorder. Journal of Affective Disorders. 2014; 160:92-7. [DOI:10.1016/j.jad.2013.12.022 ] [PMID] [DOI:10.1016/j.jad.2013.12.022]
21. Nolen Hoeksema S, Davis CG. Thanks for sharing that: Ruminators and their social support networks. Journal of Personality and Social Psychology. 1999; 77(4):801. [DOI:10.1037/0022-3514.77.4.801] [PMID] [DOI:10.1037/0022-3514.77.4.801]
22. Nolen Hoeksema S. The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology. 2000; 109(3):504-11. [DOI:10.1037/0021-843X.109.3.504] [DOI:10.1037/0021-843X.109.3.504]
23. Mansouri A, Farnam AR, Bakhshipour Rodsari A, Mahmood-Aliloo M. [Comparisons between rumination in Individual with major depresion disorder, obsessive-compulsive disorder. General Anxiety Disorder and normal persons (Persian)]. Journal of Sabzevar University of Medical Sciences. 2010; 4:26-9.
24. Pearson M, Brewin CR, Rhodes J, McCarron C. Frequency and nature of rumination in chronic depression: A preliminary study. Cognitive Behaviour Therapy. 2008; 37(3):160-8. [DOI:10.1080/16506070801919224] [PMID] [DOI:10.1080/16506070801919224]
25. Papageorgiou C, Wells A. Positive beliefs about depressive rumination: Development and preliminary validation of a self-report scale. Behaviour Therapy. 2001; 32(1):13-26. [DOI:10.1016/S0005-7894(01)80041-1]
26. Watkins E, Baracaia S. Why do people ruminate in dysphoric moods? Personality and Individual Differences. 2001; 30(5):723-34. [DOI:10.1016/S0191-8869(00)00053-2]
27. Dugas MJ, schewartz A, Francis K. Intolerance of uncertainty, worry, and depression. Cognitive Therapy and Research. 2004; 28(6):835-42. [DOI:10.1007/s10608-004-0669-0] [DOI:10.1007/s10608-004-0669-0]
28. Ladouceur R, Gosselin P, Dugas MJ. Experimental manipulation of intolerance of uncertainty: A study of a theoretical model of worry. Behaviour Research and Therapy. 2000; 38(9):933-41. [DOI:10.1016/S0005-7967(99)00133-3]
29. Grenier S, Ladouceur R. [Manipulation de Intolerance al Incertitude et Inquietudes (French)]. Revue Comedienne Dessciences du Comportment. 2004; 36(1):56-65.
30. Kendler KS. Major depression and generalised anxiety disorder: same genes, (partly) different environments-revisited. Focus. 2004; 168(3):68-425.
31. Buhr K, Dugas MJ. The intolerance of uncertainty scale: Psychometric properties of the English version. Behaviour Research and Therapy. 2002; 40(8):931-45. [DOI:10.1016/S0005-7967(01)00092-4]
32. Sexton KA, Norton PJ, Walker JR, Norton GR. Hierarchical model of generalized and specific vulnerabilities in anxiety. Cognitive Behaviour Therapy. 2003; 32(2):82-94. [DOI:10.1080/16506070302321] [PMID]
33. Muris P, Roelofs J, Meesters C, Boomsma P. Rumination and worry in nonclinical adolescents. Cognitive Therapy and Research. 2004; 28(4):539-54. [DOI:10.1023/B:COTR.0000045563.66060.3e]
34. Kraemer HC, Stice E, Kazdin A, Offord D, Kupfer D. How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. American Journal of Psychiatry. 2001; 158(6):848-56. [DOI:10.1176/appi.ajp.158.6.848] [DOI:10.1176/appi.ajp.158.6.848]
35. Frazier PA, Tix AP, Barron KE. Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology. 2004; 51(1):115-34. [DOI:10.1037/0022-0167.51.1.115] [DOI:10.1037/0022-0167.51.1.115]
36. Spasojević J, Alloy LB. Rumination as a common mechanism relating depressive risk factors to depression. Emotion. 2001;1(1):25-37. [DOI:10.1037/1528-3542.1.1.25] [PMID] [DOI:10.1037/1528-3542.1.1.25]
37. Kline RB. Principles and practice of structural equation modeling. New York: Guilford; 2010.
38. Newman MG, Zuellig AR, Kachin KE, Constantino MJ, Przeworski A, Erickson T, et al. Preliminary reliability and validity of the generalized anxiety disorder questionnaire-IV: A revised self-report diagnostic measure of generalized anxiety disorder. Behavior Therapy. 2002; 33(2):215-33. [DOI:10.1016/S0005-7894(02)80026-0] [DOI:10.1016/S0005-7894(02)80026-0]
39. Abdi R, Bakhshipour Roodsari A, Mahmood Alilou M, Farnam A. [Efficacy evaluation of unified transdiagnostic treatment in Patients with generalized anxiety disorder (Persian)]. International Journal of Behavioral Sciences. 2014; 11(5):245-51.
40. Abolghasemi A, Narimani M. [Psychological tests (Persian)]. Ardebil: Bagh-e Rezvan; 2006.
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