lesson 1: living with uncertainty - why the unknown hurts more than we think

uncertainty as stressor

no stable predictor (more stressful than knowing something very stressful will happen)

uncertainty

• a natural part of life that impacts how we make decisions and experience discomfort

• It is the inability to determine the meaning of illness-related events, occurring when the decision maker is unable to assign definite value to objects or events, or is unable to predict outcomes accurately

• It’s not simply the lack of information (in psychology)

uncertainty as psychological stressor

• Important to know why it’s such a stressor

• Multiple outcomes are possible → brain generates multiple predictions

• Uncertainty can activate our stress system

• Chronic: more often or higher intensity, environment … → increases the risk of developing psychological problems

intolerance of uncertainty (IU)

• Dispositional difficulty tolerating ‘not knowing’

• Aversive emotional response to missing information

cognitive mechanisms

Can be functional mechanisms, but in the long way, they can contribute to bad outcomes

• worry

• catastrophizing

• threat monitoring

worry

central to IU, managing uncertainty, cognitive avoidance

o Keeps the person in a specific, analytical state

o What if … (one question generates another)

o Less confidence in coping due to this

catastrophizing

worst-case scenario, focus on the most neg option

o Overestimating the neg outcome

o Exaggerating, impossible to resolve the problem

threat monintoring

something is wrong this time, scanning for all neg threats

o Strong focus on all symptoms we feel

o Behavioral inhibition as part of it

o Searching online for information, overplanning …

emotional consequences

• amplifies NA

• dampens PA

• increases emotional dysregulation over time

amplifies NA

a.    More anxiety and fear (uncertainty felt as imminent threat)

b.    More anger/irritability (uncertainty as an unfair obstacle)

c.     More sadness/demoralization (pessimistic certainty)

dampend PA

a.    Less excitement and joy, even in potentially pos contexts

b.    Less reward anticipation (especially in depression)

c.     Difficulty savoring pos moments

increased emotional dysregulation over time

a.    Self-regulatory fatigue → chronic stress, burnout (uses a lot of energy and cognitive resources)

b.    More rumination and suppression

c.     Greater vulnerability to avoidance and withdrawal

behavioral consequences

• avoidance

• safety behaviors

• control behavior

avoidance

avoiding situations with uncertain outcomes

safety behaviors

checking, reassurance-seeking, overplanning (intended to create a sense of safety, but often a false sense)

1. information seeking

2. procrastination and perfectionism

information seeking

excessive research (including digital checking) → reduces uncertainty in the moment, but teaches the brain that you can only handle this if you check

procrastination and perfectionism

delaying action to avoid uncertainty

control behavior

over-functioning to prevent mistakes (subtle approach, micromanaging)

psychological correlates

-        IU is linked to altered anticipation and salience processing

-        Outcomes in the lab (meer gestructureerd, dus opletten met outcomes)

startle

often higher during unpredictable threat

corrugator

more neg valence during anticipation

skin conductance response (SCR)

less consistent in instructed uncertainty tasks

expected uncertainty (aleatory)

predictable variability, known and stable (ex: gambling)

unexpected uncertainty

sudden change, broken expectations (ex bad and unexpected news)

epistemic uncertainty

lack of knowledge (potentially learnable)

perceptual uncertainty

ambiguous sensory input (symptom or sensation)

volatility

rules change frequently over time, changing environment (mostly in chronic illnesses with fluctuations)

deep uncertainty

probabilities unknown

shallow uncertainty

quantifiable risk

objective uncertainty

outcome not yet determined, about the future (ex soccer match)

subjective uncertainty

the outcome already exists, but you don’t know it yet (ex health quiz)

vicious cycle in GAD

1.     Message from manager asking of you can come in tomorrow to talk

2.     Triggers a threat response, many possible outcomes → what if …

3.     Coping (worrying in loops, assurance, checking their work, no longer focusing on other matters …) → worrying feels useful

4.     Relief the next day: new possibility

Cycle: their brain learns that worry brings relief

uncertainty in personality disorders

uncertainty is often experienced as a threat to …

• self-coherence

• attachment-security

• control

Leads to emotion dysregulation, impulsivity, rigid coping and interpersonal conflict

IU may act as a transdiagnostic amplifier of NA and threat interpretation (evidence is emerging, mainly indirect pathways)

self-coherence (PD)

identity: the self is stable

if weak: uncertainty becomes a threat for the self

attachment-security (PD)

relationships

will this person stay with me or not? Even low levels can trigger strong reactions (ex a different kind of message than usual)

control (PD)

rules, order, predictability

over-checking everything

amplifier = uncertainty

borderline PD (uncertainty)

o   Uncertainty about the self + relationships

o   Rapid shifts in goals/values + fear of abandonment

o   Impulsivity/self-harm as fast relief from uncertainty distress (with high costs)

OCD (uncertainty)

o   Uncertainty managed via control

o   Perfectionism, overplanning, rigidity

o   Difficulty delegation, intolerance of mistakes

avoidant PD (uncertainty)

o   Uncertainty about evaluation

o   Avoidance of social/achievement situations

o   Safety behaviors: rehearsing, reassurance, withdrawal

paranoid traits (uncertainty)

o   Ambiguity interpreted as hostile intent

o   Threat certainty replaces uncertainty (“I know they’re against me”)

chronic illness as uncertainty

-        In chronic illness, uncertainty isn’t the exception, it’s the context

-        You need meaning in order to function properly

reappraisal

changing the meaning, transforms threatening uncertainty

regulation

managing stress during the waiting period

workplace uncertainty

-        Common behavioral and emotional markers

-        Decision paralysis or extreme risk-aversion

-        Impulsive decisions (short-term certainty seeking)

-        Future-focused worry (job insecurity, organizational pessimism)

-        Withdrawal and reduced collaboration

-        Lower-quality communication (less sharing, more misunderstandings)

-        Increased frustration, anxiety, irritability

-        Disengagement (“quiet quitting”) and apathy

-        Resistance to change and new initiatives

-        Turnover intentions and loss of key talent

-        Burnout and chronic exhaustion

psychological impact (workplace uncertainty)

-        Rapid economic, technological, and organizational change drives ongoing uncertainty

-        Uncertainty erodes focus, increases cognitive load, fuels burnout, and undermines trust

-        Prolonged uncertainty causes threat monitoring and anticipatory anxiety

-        Workplace uncertainty mirrors psychological mechanisms seen in health and clinical contexts (hypervigilance, reduced cognitive capacity, decision hesitancy)

leading with clarity

1. ensure people feel valued

2. be transparant

3. set clear goals

4. be predictable

5. leverage pos emotions

manipulating uncertainty

1. probability

2. predictability

3. ambiguity

4. volatility

probability

how likely is the outcome? (ex 20% vs 80%)

predictability

can we predict when it happens? (timing)

ambiguity

are probabilities unknown? (missing information)

outcome uncertainty

what will happen?

meaning uncertainty

what does this symptom/event mean?

methods and measures

-        Self-report: IUS-12 / IUS-27 (trait IU)  state uncertainty, threat appraisal, worry, coping

-        Behavior: avoidance choices, information-seeking, decision latency//over-checking, risk-avoidance, persistence under uncertainty

-        Psychophysiology (anticipation)

-        Startle reflex (defensive responding)

-        Corrugator EMG (neg valence)

-        HR/HRV (autonomic arousal)

-        Respiration (especially relevant in health and breathlessness)

-        Neuroimaging: anterior insula, amygdala, ACC, PFC during anticipation