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Making patients aware of the possibility that an ‘intolerance of uncertainty’ is contributing to their ruminations and anxieties can be the first step towards a change in thinking and behavior
“You know me, doctor. I’m a worrier,” she said. “Always was. My mother was the very same.” She could just as easily have said her mother was responsible for her blue eyes or short stumpy legs. For her, worrying was an immutable fact of life. I made my note. “Worried about her heart. Reassured for now.”
GPs frequently see people who worry about all manner of things – sickness, death, climate change, financial disaster, their children, and their children’s children. These people live their lives on narrow tracks, avoiding all sorts of imaginary dangers, hyper-vigilant to warning signals that send them running to the safety of the consulting room, with an insatiable appetite for reassurance. I have always struggled to help these people and often felt that my conscientious listening, ritualistic examinations, and feeble attempts at reassurance were doing more harm than good. My intuition was probably correct.
In December 2019, I attended a conference in St Patrick’s Mental Health Services, entitled “The Age of Anxiety”. Prof Mark Freeston of Newcastle University talked about the construct of ‘intolerance of uncertainty’ (IU) and its relationship to anxiety and worry. Many people become a little apprehensive when faced with uncertainty, existing at what would be considered the mild end of the spectrum. At the more extreme end, this intolerance can lead to anxiety or depression. Intolerance of uncertainty also appears to be a significant separate factor in mental health disorders, such as generalised anxiety, obsessive-compulsive disorder, psychosis, and eating disorders.
Prof Freeston explained how people who have IU spend their lives thinking, ‘what if?’ Even the slightest uncertainty brings forth an inflated response. The weather, what time their child will be home for dinner, or what to buy their spouse for their birthday, present as reasons to ruminate and imagine the worst possible outcome. They have difficulty making routine decisions such as what restaurant to eat in, what book to buy, or what colour to paint their kitchen.
They may avoid thinking about these things and choose not to act because they cannot be sure of the outcome. When a threat is added to IU, life becomes more difficult. The things they cannot control loom large in their lives. Rumination on adverse outcomes leads to obsessive thoughts and behaviors. Because they avoid making plans until the results are guaranteed, they make impulsive decisions that are not in their best interest.
At the milder end of this spectrum, people, like my patient, imagine that there are positive benefits to worrying, and that excessively ruminating on something makes them better prepared if disaster should strike. They may even be convinced that by worrying, they are preventing adverse outcomes. Worrying also temporarily relieves the anxiety about the uncertainty, which leads to positive reinforcement and perpetuates the worry cycle. These are the people who seek constant reassurance.
Such people will only engage in social situations with definite outcomes, such as Mass, bingo, or a meeting that they are chairing, and may seem to function normally, but only within a narrow framework. They are prone to ritualistic behaviors and crippling self-doubt. While they often cope well with adverse events, they are at risk of depression and loneliness.
Being aware of how IU can manifest in a person’s life can help us to help them. As I have said, most of us can relate to the concept of IU at some level and can, therefore, imagine a life where it is amplified. According to Prof Freeston, when dealing with such patients, it is essential to avoid getting frustrated, which can happen, as we often feel hopeless and futile in their presence. It may help to acknowledge the possibility that it is the uncertainty rather than the actual event that is the problem and reminding them that none of us likes uncertainty in difficult times. Reassurance does not help, as I have often noticed with my patients. It simply opens the door for a new worry.
It can help to gently probe the possibility that they believe that worry might be keeping them safe by preventing bad outcomes or that it might be simply distracting their attention from their intolerance of uncertain outcomes. For most of those attending general practice, merely making them aware of the possibility that IU is contributing to their ruminations and anxieties can be the first step towards a change in thinking and behavior.
Secondary care treatments for those with mental health disorders consist of playing games that include low-stake surprises that gradually increase in significance. This might involve choosing a package and guessing what the content is while monitoring feelings and physical sensations. When I signed up for the conference, I was uncertain as to its applicability to general practice. I am glad that I did not allow this uncertainty to prevent me from going as the knowledge and insight gained have been helpful both personally and professionally while living through a pandemic.