Skip to main content
Download PDF

How deep is your thought? The relations between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa

Journal of Eating Disorders volume 9, Article number: 164 (2021) Cite this article

Abstract

Background

Inherent to anorexia nervosa are repetitive thoughts about weight and shape. Growing research suggests the relevance of intolerance of uncertainty and worry in maintaining these types of repetitive thoughts. The relation between these cognitive processes and weight and shape concerns in adolescent girls with anorexia nervosa is understudied. This study investigated associations between prospective (desire for predictability) and inhibitory (uncertainty paralysis) intolerance of uncertainty, and weight and shape concerns and the mediating role of worry in these associations.

Methods

In a cross-sectional study, 93 adolescent girls with anorexia nervosa completed questionnaires measuring the variables of interest. A mediation model with worry as a mediator between inhibitory and prospective intolerance of uncertainty and weight and shape concerns was tested.

Results

A total and direct effect of inhibitory intolerance of uncertainty on weight and shape concerns was found. Worry did not mediate this relation.

Conclusions

These results confirm the importance of inhibitory intolerance of uncertainty in adolescent girls with anorexia nervosa, more specifically to weight and shape concerns. This group may benefit from intervention strategies targeting intolerance of uncertainty. General worry seems less relevant to weight and shape concerns in adolescent girls with anorexia nervosa.

Plain English summary

Adolescent girls with anorexia nervosa often experience repetitive thoughts about weight and shape. Growing research suggests the relevance of intolerance of uncertainty and worry in maintaining these types of repetitive thoughts. Intolerance of uncertainty is defined as the incapacity to tolerate uncertainty and is often divided into two components; prospective intolerance of uncertainty (desire for predictability) and inhibitory intolerance of uncertainty (uncertainty paralysis). The relation between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa is understudied. This study aims to investigate study relations between prospective and inhibitory intolerance of uncertainty, worry, and weight and shape concerns. A total of 93 adolescent girls with anorexia nervosa completed three questionnaires, measuring prospective and inhibitory intolerance of uncertainty worry, and weight and shape concerns, respectively. The results of this study confirmed the importance of inhibitory intolerance of uncertainty in adolescent girls with anorexia nervosa, more specifically to weight and shape concerns. This group may benefit from intervention strategies targeting intolerance of uncertainty. General worry seems less relevant to weight and shape concerns in adolescent girls.

Introduction

Key diagnostic features of anorexia nervosa (AN) include the disturbance in the way in which one’s body weight and shape is experienced and undue influence of body weight and shape on self-evaluation [1]. The typical onset of AN is during adolescence or young adulthood [13] with a peak at 15 to 17 years [68]. Puberty coincides with rapid changes in body size and shape, which then must be integrated within one’s body image [58]. These rapid changes can result in increases in weight and shape concerns [11, 26, 47, 49] which, in turn, are important risk factors and maintaining factors for AN [26, 37, 69]. Weight and shape concerns entail the subjective negative appraisal of one’s body and the overvalued ideals about the personal implications of weight and shape [29]. Examining the mechanisms underlying weight and shape concerns in adolescent girls with AN might improve our understanding of the extreme body image disturbances that are frequently observed in AN. Moreover, individuals who are recovered from AN still show a partially disturbed body image [24]. A better understanding of body image disturbances in adolescent girls with AN may help to identify predictors of AN symptomology at an earlier stage of the disorder. This knowledge may translate to more suited and tailor made interventions for AN, specifically targeting IU and worry. This study sought to examine the role of worry and intolerance of uncertainty in weight and shape concerns in adolescent girls with AN.

By definition, AN involves repeatedly thinking about weight and shape, which can take up large parts of the day [61]. Indeed, literature is starting to show that these types of repetitive thoughts are part of the anxious, rigid and obsessional phenotype associated with AN [46]. Preliminary evidence suggests the relevance of a number of core cognitive anxiety-related processes to AN [66], such as intolerance of uncertainty (IU) and worry [63, 65].

IU has been defined as an individual’s dispositional incapacity to endure the aversive response triggered by the perceived absence of salient, key or sufficient information, and is sustained by the associated perception of uncertainty [14]. A number of studies reported significantly higher degrees of IU in AN compared to those with other types of eating disorders or healthy controls [10, 39, 64], however research examining IU in children and adolescent girls is scarce [43]. Two studies identified elevated levels of IU in adolescent girls with AN [28, 43]. Individuals with high levels of IU perceive uncertainty as threatening [14, 15]. In those with AN, uncertainty related to weight gain and changes in shape could easily turn into an unacceptable threat and, as a result, hinder treatment focused on weight gain. Moreover, as changes in weight and shape are one of the most dominant characteristics of adolescence, the biologically driven development of body weight and shape might become even more intolerable to adolescent girls with high IU. Preliminary evidence confirms that IU is associated with weight and shape concerns in adult women with AN [10, 28] and in non-clinical women [3]. However, studies in adolescent girls with AN have not yet been conducted.

Research has demonstrated that IU is made up of two separate but related factors: prospective IU and inhibitory IU (e.g., [4, 16, 34, 50]). Prospective IU refers to a desire for predictability that is driven by a sense of uneasiness with uncertainty [34]. It represents the negative cognitive appraisals of possible future uncertain outcomes. Inhibitory IU refers to the inhibition of action or experiences as a result of apprehension of uncertainty. Individuals high in inhibitory IU freeze up in the face of uncertainty and engage in avoidance strategies, including cognitive avoidance strategies like worry [8]. As such, inhibitory IU might be slowing down or even hindering progress in therapy when trying to use experimental or other behavioral treatment strategies to work through and diminish weight and shape concerns. Prior research has identified inhibitory IU as the most toxic component of the two as can be seen from its strong association with psychopathological symptoms and cognitive vulnerabilities such as worry in adults [4, 34], as well as in adolescents [5].

The main feature of worry is the predominance of negative-type, repetitive, and preoccupied thought about possible threatening future events [7, 75]. The predictive value of IU to worry has been firmly established across many psychiatric disorders such as generalized anxiety disorder [42], obsessive compulsive disorder [51], social anxiety [5] and eating disorders (ED; [10]); negative beliefs about uncertainty may lead to difficulty dealing with uncertainty which, in turn, may lead to excessive worry [22].

Preliminary evidence shows that worry levels are significantly higher in adults with ED compared to those without ED, and particular in people with AN [38, 63, 65]. Moreover, higher levels of worry are associated with more severe ED symptomatology, including weight and shape concerns [38, 57, 63, 66]. In addition, a study by Sternheim et al. [65] confirmed that weight and shape concerns are indeed incorporated in worries reported by adults with AN. As of yet, research has not studied this link in an adolescent population. This is relevant, because from a developmental perspective, worry is known to increase and change with age [22, 45].

Individuals affected by intolerance of negative emotions tend to use worry to avoid experiencing negative emotions [60, 77]. As worrying might serve as a distraction [73] from more distressing thought content (e.g., relationships or social problems), it is plausible that adolescent girls with AN use worry about weight and shape concerns to diminish the emotions connected with these concerns for this purpose. Moreover, a recent study indeed suggested that from a behavioral learning perspective, children prone to anxious feelings and worries may be more likely to develop concerns related to weight and body image as adolescents and may then seek out behaviors that offer mitigate these concerns [57, 59]. A handful of studies in clinical and non-clinical adult populations show that worry is indeed related to body dissatisfaction [40, 56, 57, 65] and a longitudinal study found that child worries reported by parents at age 10 were predictive of a later onset of AN at age 14 [59].

In sum, inherent to the pubertal transformation of the female body is uncertainty about both changes during this process and the grown body. Adolescent girls who have difficulties tolerating the uncertainty related to this bodily transformation process, may be expected to experience an increase in weight and shape concerns. Moreover, one could speculate that worry may impact the relation between IU and weight and shape concerns, as worry is a cognitive strategy that functions to reduce these anxiety provoking feelings of uncertainty [60, 77]. Considering the broader literature on IU and worry in emotional disorders, it is conceivable that IU precedes worry and not vice versa (e.g., [41, 45, 78]). This study aims to test associations between IU and weight and shape concerns through an indirect path via worry.

Based on previous findings (e.g., [28]), it was expected that higher levels of IU were related to higher levels of weight and shape concerns. Additionally, a positive indirect association between IU and weight and shape concerns through worry was expected. Previous studies identified inhibitory IU as the most toxic component in the context of psychopathological symptoms and worry, relative to prospective IU (e.g., [4, 34]). Hence, it was expected that the proposed mediation model was particularly salient for inhibitory IU, compared to prospective IU. The hypothesized associations between prospective and inhibitory IU with weight and shape concerns and the mediating role of worry are schematically depicted in Fig. 1.

Fig. 1
figure 1

Schematic summary of the hypothesized associations between prospective and inhibitory IU with weight and shape concerns and the mediating role of worry. Note Inhibitory IU = Inhibitory intolerance of uncertainty; Prospective IU = prospective intolerance of uncertainty

Full size image

Method

Participants and procedure

This study is part of a larger study into the geno- and phenotypes in people with EDs, conducted by a specialized treatment facility in the Netherlands. Data for the current study were extracted from this larger database. Participants were included into the current study when meeting all the following criteria: age 12 to 18 years, female gender, a DSM-5 [1] diagnosis of AN restricting (ANR) subtype or binge eating/purging (ANBP) subtype, and no missing data in the study’s variables.

Participants were recruited at the time of intake at the treatment facility, and participation took place within this same period, at the beginning of treatment. Before participating, participants were informed about the procedure and were given the opportunity to ask questions about the study. Participants who then signed the informed consent form were enrolled in the study. The EDE interview was administered by trained advanced clinical psychology students at the treatment facility. The EDE interview is part of the intake procedure and is scheduled to take approximately 60 min. All other measures were completed on a computer at the treatment facility, which were programmed using Inquisit software (version 4; Millisecond, 2016). Participants were told to read the instructions of each questionnaire carefully. Completing the entire test battery took approximately 45–60 min. The researcher was nearby, in case there were any questions. Afterwards, participants were debriefed and given the opportunity to indicate whether or not they wanted to be informed about the results of the study. The research protocol was authorized by the Committee Scientific Research of Altrecht Mental Health Institute and the Medical Ethical Committee of the University Medical Center Utrecht.

Measures

Intolerance of uncertainty

The Intolerance of Uncertainty Scale (IUS-12; [16]) measures one’s IU as expressed in several domains, including emotion, cognition and behavior. It has two subscales, tapping prospective IU and inhibitory IU, respectively. Respondents rate the degree to which each of 12 items apply to them on 5-point Likert scale ranging from 1 (not at all characteristic of me) to 5 (entirely characteristic of me). An example of an item of the prospective IU subscale is “It frustrates me not having all the information I need.” An example of the inhibitory IU subscale is “When it is time to act, uncertainty paralyses me”. Subscale scores were calculated by summing up the respective items, with higher scores indicating higher levels of IU. The Dutch version of the IUS-12 has good psychometric properties [33]. In the current study, the IUS-12 total had a good internal consistency (α = 0.89), the internal consistency of the prospective IU subscale was considered good (α = 0.86) and that of the inhibitory IU subscale (α = 0.75) was considered acceptable.

Worry

The Penn State Worry Questionnaire (PSWQ; [52]) contains 16 items that assess pathological worry on a 5-point Likert scale ranging from 1 (not at all typical) to 5 (very typical). An example item is “My worries overwhelm me.” Total scores were calculated by summing all the item scores (after reversing some of them), resulting in a possible range of 16 to 80. Higher scores indicate higher levels of pathological worry. The Dutch PSWQ has very good psychometric properties [38]. The PSWQ had good internal consistency in the current study (α = 0.84).

Weight and shape concerns

The Dutch version of the Eating Disorder Examination (EDE, 12th edition; [25, 36]) was conducted and is widely regarded as the “Gold Standard’ to measure of eating disorder psychopathology and behaviors. It is an investigator-based clinical interview that provides a comprehensive assessment of the frequency and the severity of key behavioral and psychological aspects of eating disorders [25]. It focuses on the past 28 days and assesses the main behavioral and attitudinal features of eating disorders. The behavioral features are measured in terms of their frequency and the number of days on which they occurred. For the remaining items, the interviewer rates the participant’s response on a 0–6 scale of severity, with higher scores indicating greater levels of psychopathology. It comprises four subscales: Restraint, Shape Concern, Weight Concern and Eating Concern. For the purpose of this study only the subscales Weight Concern and Shape Concern are used. The mean of the items of these subscales was calculated, considering that factor analysis suggests that the items of both subscales generally load on one factor [74]. The EDE has demonstrated good internal consistency, inter-rater reliability and convergent and discriminant validity for the subscales in samples of adolescents [70]. Wade et al. [74] reported an excellent internal reliability for the weight and shape subscales (α = 0.91).

Statistical analysis

The statistical analyses were performed using IBM SPSS Statistics Version 26 [35] and PROCESS for SPSS v3.0 [32]. Scores on IUS12 and EDE were normally distributed. Scores on the PSWQ slightly violated the assumption of normality [27] and some outliers were detected. However, the sample of this study was large enough (N > 40) to be able to use parametric procedures without causing any major problems, despite PSWQ data not being normally distributed [30]. First of all, bivariate associations between the study variables were analysed using Pearson’s correlation coefficients. Then, a mediation analysis with prospective IU and inhibitory IU as predictors, worry as mediator and weight and shape concerns as criterion variable was conducted. The mediation analysis comprises the following steps ([32]; model 4): first, in order to estimate the unique effects of prospective and inhibitory IU on worry, a multiple regression analysis was performed. Second, a hierarchical regression analysis was run in order to estimate the unique total effects of prospective and inhibitory IU (Step 1) and the unique direct effects of prospective and inhibitory IU as well as worry (Step 2) on weight and shape concerns. Third, the unique indirect effects of prospective and inhibitory IU on weight and shape concerns via worry were determined by means of bootstrap analyses with 5000 bootstrap samples [32]. With regard to the direct and indirect effects, PROCESS model 4 was carried out two times,each time putting one dimension of IU as predictor and the other dimension as control variable. Each time PROCESS was run, the direct and indirect effect of the predictor was estimated. Mathematically, all resulting paths, direct and indirect will be the same as if they had been estimated simultaneously (as in a structural equation modeling program; [32]. As previous research has shown that certain features could impact the clinical presentation of AN (e.g., [2]), age of onset, duration of illness and BMI were entered as control variables as well. Standardized coefficients are reported. To determine the efficacy of the regression model, Cohen f2 effect sizes were calculated [20].

Results

Descriptive statistics

A total of 93 participants (76 ANR and 17 ANBP) participated in this study. Participants had an average age of 15.91 years (SD = 1.64) and an average amount of educational years of 10.44 (SD = 2.19). The average global EDE score was 3.4 (SD = 1.23), which was lower than the global EDE score (4.0; SD = 1.5) found in a similar sample [12]. The average BMI was 16.93 (SD = 2.17), placing the BMI-for-age at the sixth percentile just within the range of a healthy weight (below the fifth percentile is indicative for underweight [17]; https://www.cdc.gov). The average age of onset of AN was 14.11 (SD = 1.67), and the average illness duration was 1.80 years (SD = 1.51). Table 1 displays the means, standard deviations and the bivariate correlations between the study’s variables. The levels of prospective and inhibitory IU found in this study were higher in comparison to a nonclinical adolescent population [5]. In addition, the levels of worry obtained in this study were comparable to a nonclinical adolescent female group [53] and clinical adults with AN [57], however, lower than the levels found in adults with AN of other studies [63, 64]. The levels of weight and shape concerns found in this study fell within the range to be expected in a clinical sample of adolescent girls with AN [12]. A moderate correlation was found between prospective IU, inhibitory IU and worry. The correlation between inhibitory IU and weight and shape concerns was considered moderate and the associations prospective IU and weight and shape concerns was weak. Worry did not correlate with weight and shape concerns.

Table 1 Means, standard deviations and bivariate correlations of analysis measures (N = 93)
Full size table

Total, direct, and indirect effects of prospective and inhibitory IU on weight and shape concerns through worry

The multiple regression analysis revealed a significant effect of prospective IU and a nonsignificant effect of inhibitory IU (see Fig. 2). A total of 25.4% of the variance in worry could be explained, F(5, 87) = 5.910, p < 0.001; Cohen’s f2 = 0.34, which is considered a medium (but near to a large) effect [20].

Fig. 2
figure 2

Results of the regression analysis. Note Inhibitory IU = Inhibitory intolerance of uncertainty; Prospective IU = prospective intolerance of uncertainty. Coefficients in parentheses represent total effects. Coefficients highlighted in bold are significant of p < .01, when controlling for age of onset, duration of illness and BMI

Full size image

The hierarchical regression revealed a nonsignificant negative total effect of prospective IU and a significant positive total effect of inhibitory IU in Step 1. In addition, a nonsignificant negative direct effect of prospective IU on weight and shape concerns was revealed and a significant positive effect of inhibitory IU on weight and shape concerns in Step 2 (see Fig. 2). Furthermore, in Step 2, a nonsignificant negative effect of worry on weight and shape concerns was found (see Fig. 2). A total of 27.4% of the variance in weight and shape concerns could be explained F(6, 86) = 5.416, p < 0.001; Cohen’s f2 = 0.38, which is considered a large effect [20].

The bootstrap analyses revealed a nonsignificant negative indirect effect of prospective IU,.-0.003, BC 95% confidence interval (CI) [0.04, − 0.09], and a nonsignificant negative indirect effect of inhibitory IU, − 0.002, BC 95% CI [0.03, − 0.05], on weight and shape concerns through worry. Worry thus did not mediate the relationship of both prospective IU and inhibitory IU with weight and shape concerns.

Discussion

The present study investigated the relationships of prospective IU and inhibitory IU with worry and weight and shape concerns. More specifically, the mediating role of worry in the associations between the IU dimensions and weight and shape concerns was examined. Taken together, our results partly confirmed our hypotheses.

Regarding our IU hypotheses, we expected higher levels of inhibitory IU to be associated with weight and shape concerns, relative to prospective IU. Indeed, only the association of inhibitory IU with weight and shape concerns was found. This study was the first, to the best of our knowledge, to investigate relations between weight and shape concerns and the two components of IU separately in a clinical adolescent AN sample. Our expectations were based on previous clinical studies finding total scores of IU associated with weight and shape concerns in AN [28] and on results from a study by Boelen and Lenferink [4], suggesting that clinically inhibitory IU may be of more importance to more severe ED symptomatology. Indeed results confirm the importance of inhibitory IU to AN, and specifically to weight and shape concerns, which is reflected in the large effect size.

Although the levels of worry were in accordance with the levels of worry found by Sassaroli et al. [57], levels were not as high as found in more recent studies of adults with AN [63]. Worry levels in the present study can be interpreted as moderate,individuals that can be bothered by worries but are just below clinical range for worry [52]. Moderate worry still serves as an adaptive process as it prepares individuals for future threat and increases motivation among other things [21, 62]. However, when moderate worry turns into pathological worry it becomes of clinical concern. Notably, interpreting these results is a relatively complex matter as this is first study investigating worry in adolescent girls with AN which makes it impossible to compare current results to other studies investigating a similar population. Additionally, as excessive worry is often observed in adults with AN, it is suggested that worry levels should always be monitored closely in therapy and targeted when necessary as worry is suggested to be particular relevant for AN development which may contribute to shared risk to anxiety disorders and AN [48, 59].

Interestingly, whilst clinical levels of worry have been detected in adults with AN (e.g., [65]), we failed to establish an association between worry and weight and shape concerns and as a result we did not replicate these findings in the present sample of adolescent girls with AN. One explanation might be related to the contents of worry. As worry becomes increasingly elaborate and abstract during adolescence [72], contents shift from worrying about e.g., the monster under the bed in childhood to more broader psychopathological issues such as the fear of rejection or the fear of being evaluated negatively in puberty [45, 64]. One could speculate that adolescent girls with AN feel overwhelmed by and struggle with managing these changes and that as a possible result, they fill the content of their worries with ED—specific worries which at this stage makes them feel safe and in control. It has been suggested that worry serves the short-term purpose of distraction or relief from more terrifying thoughts (e.g., relationships or social problems), but may lead to weight and shape concerns at a later stage [56]. Indeed, a recent longitudinal study found that child worries reported by parents at age 10 were predictive of a later onset of AN at age 14 and more specifically of body dissatisfaction and weight concerns [59]. As such, worry may still function as a facilitator of positive beliefs about worry (e.g., worrying can reduce uncertainty; [23]) in adolescent girls with AN and is not yet experienced as a salient component of the repetitive thoughts that are bothering many adults with AN during the entire day. To examine this theory, longitudinal studies are required assessing these developmental elements in these relations in patients with AN during their transition from adolescence into adulthood. Future studies should also explore the exact nature of worry but also its different functions to further clarify the complexity of this construct.

Regarding the associations of prospective and inhibitory IU and worry, it was found that only prospective IU was related to worry when controlling for inhibitory IU. Specifically, these higher levels of prospective IU and its association with higher levels of worry do not corroborate with earlier studies in nonclinical adolescents [5] and nonclinical adults [4]. In these studies, it was found that higher levels of inhibitory IU were associated with higher levels of worry, although worry levels were much lower in both studies. Nonetheless, this study replicates findings from other studies that highlight IU as an important contributing factor to worry (e.g., [65]). In addition, differentiating between prospective and inhibitory IU in the association with worry might impact approaches in intervention. Findings from the present study contribute to a growing body of literature positing IU as an important factor that can be linked to the development and maintenance symptoms of AN such as weight and shape concerns [28, 64, 67]. Previous studies have shown that IU is a malleable mechanism and CBT-type interventions for IU have shown success in reducing IU [9]. Furthermore, experimental studies in adult samples have shown that changes in IU lead to corresponding changes in worry [31, 44, 54, 55]. One could argue that adolescent girls with AN may benefit from additional interventions that target IU as well as diminishing levels of IU might help to prevent worry from growing and becoming an integrative part of the repetitive thinking style as observed in adult populations with AN [65].

As of yet, we do not know whether addressing IU will also help to lower levels of weight and shape concerns, possibly contributing to an improved path to recovery. Individuals with AN who experience more severe ED pathology problems such as weight and shape concerns are more likely to have a worse outcome and may be at greater risk of dropping out of treatment [71]. IU might well be part of the mechanism underlying these body image disturbances. Future research should focus on body image related IU and how to target this in interventions that are suitable for adolescent girls with AN. It may be beneficial to address IU among individuals with AN in order to prevent worry from becoming part of the repetitive thinking style and diminish ED symptoms such as weight and shape concerns along the way.

Some limitations need to be acknowledged. Due to the cross-sectional design, the direct of causality in the associations between the constructs could not definitely be determined [76]. Furthermore, whilst a large majority of cross-sectional and treatment studies have identified IU as a predictor of worry rather than vice versa (e.g., [41, 78]), there are a couple of studies that suggest a reciprocal relation, with worry contributing to IU (e.g., [6]). The current dataset only allowed for investigating cross-sectional associations and longitudinal studies may show the developmental patterns of IU and worry in adolescent girls with AN over time. In addition, a longitudinal study that could start in early adolescence and follow up into adulthood would provide a better insight in the development of the transition of nonclinical worry in an adolescent sample into pathological levels of worry as is seen in an adult AN sample (e.g., [63, 65]). Furthermore, future might focus on for instance general worry as well as on positive beliefs about worry and eating disorder specific worry. In doing so, the precise nature and function of worry might be further unraveled and result into an improved understanding of worry. Although the carefully selected PSWQ has been the most widely-used measure of the frequency, intensity, and uncontrollability of worry and it has been employed within both clinical and non-clinical populations [52], it could well be that other instruments would have been more suited to capture the construct of worry within a population of adolescent AN girls with a mean age of almost 16 years old. Using the PSWQ provided the option to at least compare our results to adult studies. Moreover, given the mean age of the studied population the PSWQ seemed more appropriate than the PSWQ-Children [18] or studies that use instruments that are tapping into more general anxiety symptoms but not specifically into worry itself (e.g., the revised children’s anxiety and depression scale; [19]). Lastly, the present sample largely comprised adolescent girls with the restrictive subtype of AN, relative to the binge/purge subtype. Additionally, as this study was novel in investigating relations between IU, worry and weight and shape concerns in adolescent girls, it was decided to investigate the sample as a whole rather than in subtypes. However, future studies may focus on distinguishing subtypes of AN.

Conclusions

In sum, this study contributes to the understanding of distinguishing components of IU and their associations with weight and shape concerns as it partly confirms our expectancy; inhibitory (but not prospective) IU co-occurs with weight and shape concerns in a large adolescent AN sample. This might indicate the importance of core cognitive anxiety-related processes such as IU in adolescent girls with AN. Furthermore, special attention could be given to the role of inhibitory IU within research as well as in interventions. A better understanding of inhibitory IU and weight and shape concerns might be helping in disentangling the complexity of body image disturbances, especially in adolescent girls when biologically driven changes of their bodies might lead an intolerable feeling of uncertainty. In contrast to our expectations, worry does not seem to be integrated in the cognitive processes of adolescent girls with AN as of yet. The precise nature and function of general worry seems to be more complex to interpret.

Availability of data materials

Supporting data are unfortunately unavailable as a consequence of the strict regulations regarding the privacy of the patients.

Abbreviations

AN:

Anorexia nervosa

ANR:

Anorexia nervosa restrictive subtype

ANBP:

Anorexia nervosa binge/purge subtype

APA:

American Psychiatric Association

DSM-5:

Diagnostic and Statistical Manual of mental Disorders

ED:

Eating disorders

EDE:

Eating Disorder Examination

CBT:

Cognitive behavioral therapy

IU:

Intolerance of uncertainty

IUS-12:

Intolerance of uncertainty scale

PSWQ:

Penn State Worry Questionnaire

References

  1. American Psychiatric Association. The diagnostic and statistical manual of mental disorders, fifth edition: DSM 5. Virginia: American Psychiatric Association; 2013.

    Book  Google Scholar 

  2. Accurso EC, Ciao AC, Fitzsimmons-Craft EE, Lock JD, Le Grange D. Is weight gain really a catalyst for broader recovery? The impact of weight gain on psychological symptoms in the treatment of adolescent anorexia nervosa. Behav Res Ther. 2014;56:1–6. https://doi.org/10.1016/j.brat.2014.02.00.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Bijsterbosch JM, van den Brink F, Vollmann M, Boelen PA, Sternheim LC. Understanding relations between intolerance of uncertainty, social anxiety, and body dissatisfaction in women. J Nerv Ment Dis. 2020;208(10):833–5. https://doi.org/10.1097/NMD.000000000000120.

    Article  PubMed  Google Scholar 

  4. Boelen PA, Lenferink LIM. Latent class analysis of indicators of intolerance of uncertainty. Scand J Psychol. 2018;59:243–51. https://doi.org/10.1111/sjop.12440.

    Article  PubMed  Google Scholar 

  5. Boelen PA, Vrinssen I, van Tulder F. Intolerance of uncertainty in adolescents: correlated with worry, social anxiety, and depression. J Nerv Ment Disord. 2010;198(3):194–200. https://doi.org/10.1097/NMD.0b013e3181d143de.

    Article  Google Scholar 

  6. Bomyea J, Ramsawh H, Ball TM, Taylor CT, Paulus MP, Lang AJ, Stein MB. Intolerance of uncertainty as a mediator of reductions in worry in a cognitive behavioral treatment program for generalized anxiety disorder. J Anxiety Disord. 2015;33:90–4. https://doi.org/10.1016/j.janxdis.2015.05.004.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Borkovec TD. The nature, functions, and origins of worry. In: Davey GCL, Tallis F, editors. Worrying: perspectives on theory, assessment, and treatment. Chichester: Wiley; 1994.

    Google Scholar 

  8. Borkovec TD, Ray WJ, Stober J. Worry: a cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes. Cogn Ther Res. 1998;22:561–76.

    Article  Google Scholar 

  9. Boswell JF, Thompson-Hollands J, Farchione TJ, Barlow DH. Intolerance of uncertainty: a common factor in the treatment of emotional disorders. J Clin Psychol. 2013;69:630–45. https://doi.org/10.1002/jclp.21965.

    Article  PubMed  Google Scholar 

  10. Brown M, Robinson L, Campione GC, Wuensch K, Hildebrandt T, Micali N. Intolerance of uncertainty in eating disorders: a systematic review and a meta-analysis. Eur Eat Disord Rev. 2017;25:329–43. https://doi.org/10.1002/erv.2523.

    Article  PubMed  Google Scholar 

  11. Bucchianeri MM, Arikian AJ, Hannan PJ, Eisenberg ME, Neumark-Sztainer D. Body dissatisfaction from adolescence to young adulthood: findings from a 10-year longitudinal study. Body Image. 2013;10(10):1–7. https://doi.org/10.1016/j.bodyim.2012.09.001.

    Article  PubMed  Google Scholar 

  12. Calguli S, Dalle Grave R. Body image concern and treatment outcomes in adolescents with anorexia nervosa. Int J Eat Disord. 2019;52:582–5. https://doi.org/10.1002/eat.23031.

    Article  Google Scholar 

  13. Campbell K, Peebles R. Eating disorders in children and adolescents. Pediatrics. 2014;134(3):582–92. https://doi.org/10.1542/peds.2014-0194.

    Article  PubMed  Google Scholar 

  14. Carleton RN. Into the unknown: a review and synthesis of contemporary models involving uncertainty. J Anxiety Disord. 2016;39:30–43. https://doi.org/10.1016/j.janxdis.2016.02.007.

    Article  PubMed  Google Scholar 

  15. Carleton RN. Fear of the unknown: one fear to rule them all? J Anxiety Disord. 2016;41:5–21. https://doi.org/10.1016/j.janxdis.2016.03.011.

    Article  PubMed  Google Scholar 

  16. Carleton RN, Norton PJ, Asmundson GJG. Fearing the unknown: a short version of the intolerance of uncertainty scale. J Anxiety Disord. 2007;21:105–17. https://doi.org/10.1016/j.janxdis.2006.03.014.

    Article  PubMed  Google Scholar 

  17. Centers for Disease Control and prevention (2021) BMI percentile calculator for child and teen. https://www.cdc.gov/healthyweight/bmi/calculator.html

  18. Chorpita BF, Tracey SA, Brown TA, Collica TJ, Barlow DH. Assessment of worry in children and adolescents: an adaptation of the Penn State Worry Questionnaire. Behav Res Ther. 1997;35(6):569–81. https://doi.org/10.1016/s0005-7967(96)00116-7.

    Article  PubMed  Google Scholar 

  19. Chorpita BF, Yim L, Moffitt C, Umemoto LA, Francis SE. Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale. Behav Res Ther. 2000;38(8):835–55. https://doi.org/10.1016/s0005-7967(99)00130-8.

    Article  PubMed  Google Scholar 

  20. Cohen J. A power primer. Psychol Bull. 1992;112(1):155–9. https://doi.org/10.1037/0033-2909.112.1.155.

    Article  PubMed  Google Scholar 

  21. Davey GCL, Hampton J, Farrell J, Davidson S. Some characteristics of worrying: evidence for worrying and anxiety as separate constructs. Pers Individ Differ. 1991;13(2):133–214. https://doi.org/10.1016/0191-8869(92)90036-O.

    Article  Google Scholar 

  22. Dugas MJ, Laugesen N, Bukowski WM. Intolerance of uncertainty: fear of anxiety, and adolescent worry. J Abnorm Child Psychol. 2012;40:838–70. https://doi.org/10.1007/s10802-012-9611-1.

    Article  Google Scholar 

  23. Dugas MJ, Koerner N. Cognitive-behavioral treatment for generalized anxiety disorder: current status and future. Dir J Cogn Psychotherap. 2005;19:61–81. https://doi.org/10.1891/088983905780907252.

    Article  Google Scholar 

  24. Engel MM, Keizer A. Body representation disturbances in visual perception and affordance perception persist in eating disorder patients after completing treatment. Sci Rep. 2017;7:16184. https://doi.org/10.1038/s41598-017-16362-w.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Fairburn CG, Cooper Z. The eating disorder examination (12th edition). In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment, and treatment. New York: Guilford Press; 1993. p. 317–60.

    Google Scholar 

  26. Fairburn CG, Cooper Z, Shafran R. Cognitive behavior therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther. 2003;41(5):509–28. https://doi.org/10.1016/s0005-7967(02)00088-8.

    Article  PubMed  Google Scholar 

  27. Field A. Discovering statistics using SPSS. 5th ed. London: Sage; 2018.

    Google Scholar 

  28. Frank GK, Roblek T, Shott ME, Jappe LM, Rollin MD, Hagman JO, Pryor T. Heightened fear of uncertainty in anorexia and bulimia nervosa. Int J Eat Disord. 2012;45(2):227–32. https://doi.org/10.1002/eat.20929.

    Article  PubMed  Google Scholar 

  29. Garner DM, Garfinkel PE. Body image in anorexia nervosa: measurement, theory and clinical implications. Int J Psychiatry Med. 1982;157(11):1799–805.

    Google Scholar 

  30. Ghasemi A, Zahediasl A. Normality tests for statistical analysis: a guide for non-statisticians. Int J Endocrinol Metab. 2012;2:486–9. https://doi.org/10.5812/ijem.3505.

    Article  Google Scholar 

  31. Grenier S, Ladouceur R. Manipulation de l’intolerance a l’incertitude et inquietudes [Manipulation of intolerance of uncertainty]. Can J Behav Sci. 2004;36:56–65. https://doi.org/10.1037/h0087216.

    Article  Google Scholar 

  32. Hayes AF. Introduction to mediation, moderation, and conditional process analysis second edition: a regression-based approach. New York: Guilford Press; 2018.

    Google Scholar 

  33. Helsen K, Van den Bussche E, Vlaeyen JWS, Goubert L. Less is more. Confirmatory factor analysis of the Dutch Intolerance of Uncertainty Scale: comparison of the full and short version. J Behav Ther Exp Psychiatry. 2013;44:21–9. https://doi.org/10.1016/j.jbtep.2012.07.004.

    Article  PubMed  Google Scholar 

  34. Hong RY, Lee SSM. Further clarifying prospective and inhibitory intolerance of uncertainty: factorial and construct validity of test scores from the Intolerance of Uncertainty Scale. Psychol Assess. 2015;272:605–20. https://doi.org/10.1037/pas0000074.

    Article  Google Scholar 

  35. IBM Corp Released. IBM SPSS statistics for windows, version 26.0. Armonk: IBM Corp; 2019.

    Google Scholar 

  36. Jansen A. Eating disorder examination (EDE 12.0). Interview ter vaststelling van de specifieke psychopathologie van eetstoornissen. Lisse: Swets & Zeitlinger; 2000.

    Google Scholar 

  37. Keel PK, Dorer DJ, Franko DL, Jackson SC, Herzog DB. Postremission predictors of relapse in women with eating disorders. Am J Psychiatry. 2005;162:2263–8. https://doi.org/10.1176/appi.ajp.162.12.2263.

    Article  PubMed  Google Scholar 

  38. Kerkhof A, Hermas D, Figee A, Laeremans I, Pieters G. De Penn State Worry Questionnaire en de Worry Domains Questionnaire: eerste resultaten bij Nederlandse en Vlaamse Klinische en poliklinische populaties [Penn State Worry Questionnaire and the Worry Domains Questionnaire: first results in Dutch and Flemish in- and outpatient groups]. Gedragstherapie. 2000;33(2):135–45.

    Google Scholar 

  39. Kesby A, Maguire S, Brownlow R, Grisham J. Intolerance of uncertainty in eating disorders: an update on the field. Clin Psychol Rev. 2017;56:94–105. https://doi.org/10.1016/j.cpr.2017.07.002.

    Article  PubMed  Google Scholar 

  40. Kesby A, Maguire S, Vartaniana LR, Grisham JR. Intolerance of uncertainty and eating disorder behaviour: piloting a consumption task in a non-clinical sample. J Behav Ther Exp Psychiatry. 2019. https://doi.org/10.1016/j.jbtep.2019.101492.

    Article  PubMed  Google Scholar 

  41. Koerner N, Dugas MJ. An investigation of appraisals in individuals vulnerable to excessive worry: the role of intolerance of uncertainty. Cogn Ther Res. 2008. https://doi.org/10.1007/s10608-007-9125-2.

    Article  Google Scholar 

  42. Koerner N, Meija T, Kusec A. What’s in the name? Intolerance of uncertainty, other uncertainty-relevant constructs, and their differential relations to worry and generalized anxiety disorder. Cogn Behav Ther. 2017;46(2):141–61. https://doi.org/10.1080/16506073.2016.1211172.

    Article  PubMed  Google Scholar 

  43. Konstantellou A, Hale L, Sternheim L, Simic M, Eisler I. The experience of intolerance of uncertainty for young people with a restrictive eating disorder: a pilot study. Eat Weight Disord Studies Anorexia Bulimia Obes. 2019;24:533–40. https://doi.org/10.1007/s40519-019-00652-5.

    Article  Google Scholar 

  44. Ladouceur R, Gosselin P, Dugas MJ. Experimental manipulation of intolerance of uncertainty: a study of a theoretical model of worry. Behav Res Ther. 2000;38:933–41. https://doi.org/10.1016/S0005-7967(99)00133-3.

    Article  PubMed  Google Scholar 

  45. Laugesen N, Dugas MJ, Bukowski WM. Understanding adolescent worry: the application of a cognitive model. J Abnorm Child Psychol. 2003;31:55–64. https://doi.org/10.1023/a:1021721332181 (PMID: 12597699).

    Article  PubMed  Google Scholar 

  46. Levinson CA, Brosof LC, Shankar Ram S, Pruitt A, Russell S, Lenze EJ. Obsessions are strongly related to eating disorder symptomatology in anorexia nervosa and atypical anorexia nervosa. Eat Behav. 2019;34: 101298. https://doi.org/10.1016/jeatbeh.2019.05.001.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Linardon J, Phillipou A, Castle D, Newton R, Harrison P, Cistullo LL, Griffths S, Hindle A, Brennan L. The relative associations of shape and weight overevaluation, preoccupation, dissatisfaction, and fear of weight gain with measures of psychopathology: an extension study in individuals with anorexia nervosa. Eat Behav. 2018;29:54–8. https://doi.org/10.1016/j.eatbeh.2018.03.002.

    Article  PubMed  Google Scholar 

  48. Lloyd EC, Sallis HM, Verplanken B, Haase AM, Munafò MR. Understanding the nature of association between anxiety phenotypes and anorexia nervosa: a triangulation approach. BMC Psychiatry. 2020;7:495. https://doi.org/10.1186/s12888-020-02883-8.

    Article  Google Scholar 

  49. Lydecker JA, White MA, Grilo CM. Form and formulation: examining the distinctiveness of body image constructs in treatment-seeking patients with binge-eating disorder. J Consult Clin Psychol. 2017;85(11):1095–103. https://doi.org/10.1037/ccp0000258.

    Article  PubMed  PubMed Central  Google Scholar 

  50. McEvoy PM, Mahoney AEJ. Achieving certainty about the structure of intolerance of uncertainty in a treatment-seeking sample with anxiety and depression. J Anxiety Disord. 2011;25:112–22. https://doi.org/10.1016/j.janxdis.2010.08.010.

    Article  PubMed  Google Scholar 

  51. McEvoy PM, Mahoney AEJ. To be sure, to be sure: intolerance of uncertainty mediates symptoms of various anxiety disorders and depression. Behav Ther. 2012;43:533–45. https://doi.org/10.1016/j.beth.2011.02.007.

    Article  PubMed  Google Scholar 

  52. Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the penn state worry questionnaire. Behav Res Ther. 1990;28(6):487–95.

    Article  PubMed  Google Scholar 

  53. Pace U, Passanisi A, D’Urso G. Emotional and cognitive correlations of hating among adolescents: an exploratory study. J Adolesc. 2018;68:159–64. https://doi.org/10.1016/j.adolescence.2018.08.002.

    Article  PubMed  Google Scholar 

  54. Rosen NO, Knäuper B. A little uncertainty goes a long way: state and trait differences in uncertainty interact to increase information seeking but also increase worry. Health Commun. 2009;24:228–38. https://doi.org/10.1080/10410230902804125.

    Article  PubMed  Google Scholar 

  55. Rosen NO, Knäuper B, Sammut J. Do individual differences in intolerance of uncertainty affect health monitoring? Psychol Health. 2007;22:413–30. https://doi.org/10.1080/14768320600941038.

    Article  Google Scholar 

  56. Sala M, Levinson CA. The longitudinal relationship between worry and disordered eating: is worry a precursor or consequence of disordered eating? Eat Behav. 2016;23:28–32. https://doi.org/10.1016/jeatbeh.2016.07.012.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Sassaroli S, Bertilli S, Decoppi M, Crosima M, Milos G, Ruggiero GM. Worry and eating disorders: a pathological association. Eat Behav. 2005;6:201–307. https://doi.org/10.1002/eat.20079.

    Article  Google Scholar 

  58. Sattler FA, Eickmeyer S, Eisenkolb J. Body image disturbances in children and adolescents with anorexia nervosa and bulimia nervosa: a systematic review. Eight Weight Disord Studies Anorexia Bulimia Obes. 2019;25:857–65. https://doi.org/10.1007/s40519-019-00725-5.

    Article  Google Scholar 

  59. Schaumberg K, Zerwas S, Goodman E, Yilmaz Z, Bulik CM, Micali N. Anxiety disorder symptoms at age 10 predict eating disorder symptoms and diagnoses in adolescence. J Child Psychol Psychiatry. 2019;60(6):686–96. https://doi.org/10.1111/jcpp.12984.

    Article  PubMed  Google Scholar 

  60. Schmidt U, Treasure J. Anorexia nervosa: valued and visible. A cognitive interpersonal maintenance model and its implications for research and practice. Br J Clin Psychol. 2006;45:343–66. https://doi.org/10.1348/014466505X53902.

    Article  PubMed  Google Scholar 

  61. Seidel M, Petermann J, Diestal S, Ritschel F, Boehm I, King JA, Geisler D, Bernardoni F, Roessner V, Goschke T, Erlich S. A naturalistic examination of negative affect and disorder-related rumination in anorexia nervosa. Eur Child Adolesc Psychiatry. 2016;25:1207–16.

    Article  PubMed  Google Scholar 

  62. Songco A, Hudson JL, Fox E. A cognitive model of pathological worry in children and adolescents: a systematic review. Clin Child Fam Psychol Rev. 2020;23(2):229–49. https://doi.org/10.1007/s10567-020-00311-7.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Startup H, Lavender A, Oldershaw A, Stott R, Tchanturia K, Treasure J, Schmidt U. Worry and rumination in anorexia nervosa. Behav Cogn Psychother. 2013;41(3):301–16. https://doi.org/10.1017/S1352465812000847.

    Article  PubMed  Google Scholar 

  64. Sternheim L, Konstantellou A, Startup H, Schmidt NB. What does un- certainty mean to women with anorexia nervosa? An interpretative phenomenological analysis. Eur Eat Disord Rev. 2011;19:12–24. https://doi.org/10.1136/bmj.a288.

    Article  PubMed  Google Scholar 

  65. Sternheim L, Startup H, Schmidt U. An experimental exploration of behavioral and cognitive-emotional aspects of intolerance of uncertainty in eating disorder patients. J Anxiety Disord. 2012;25(6):806–12. https://doi.org/10.1016/j.janxdis.2011.03.020.

    Article  Google Scholar 

  66. Sternheim L, Startup H, Schmidt U. Anxiety-related processes in anorexia nervosa and their relation to eating disorder pathology, depression and anxiety. Adv Eat Disord. 2015;3:13–9. https://doi.org/10.1080/21662630.2014.948469.

    Article  Google Scholar 

  67. Sternheim L, Fisher M, Harrison A, Watling R. Predicting intolerance of uncertainty in individuals with eating disorder symptoms. J Eat Disord. 2017;5:26–35. https://doi.org/10.1186/s40337-017-0152-4.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Smink FR, van Hoeken D, Hoek HW. Epidemiology, course, and outcome of eating disorders. Curr Psychiatry Rep. 2013;26(6):543–8. https://doi.org/10.1007/s11920-012-0282-y.

    Article  Google Scholar 

  69. Stice E, Shaw HE. Role of body dissatisfaction and maintenance of eating pathology A synthesis of research findings. J Psychosom Res. 2002;53:985–93.

    Article  PubMed  Google Scholar 

  70. Vannucci A, McCauley Ohannessias C. Body image dissatisfaction and anxiety trajectories during adolescence. J Clin Child Adolesc Psychol. 2018;47:785–95. https://doi.org/10.1080/15374416.2017.1390755.

    Article  PubMed  Google Scholar 

  71. Vall E, Wade TD. Predictors of treatment outcome in individuals with eating disorders: a systematic review and meta-analysis. Int J Eat Disord. 2015;48(7):946–71. https://doi.org/10.1002/eat.22411.

    Article  PubMed  Google Scholar 

  72. Vasey MW. Development and cognition in childhood anxiety: the example of worry. In: Ollendick TH, Prinz RJ, editors. Advances in clinical child psychology, vol. 15. New York: Plenum; 1993. p. 1–39.

    Google Scholar 

  73. Vasey MW, Borkovec TD. A catastrophizing assessment of worrisome thoughts. Cogn Ther Res. 1992;16:505–20. https://doi.org/10.1007/BF01175138.

    Article  Google Scholar 

  74. Wade TD, Byrne S, Bryant-Waugh R. The eating disorder examination: norms and construct validity with young and middle adolescent girl. Int J Eat Disord. 2008;41:551–8.

    Article  PubMed  Google Scholar 

  75. Watkins E. Adaptive and maladaptive ruminantive self-focus during emotional processing. Behav Res Ther. 2004;42(9):1037–52. https://doi.org/10.1016/j.brat.2004.01.009.

    Article  PubMed  Google Scholar 

  76. Winer ES, Cervone D, Bryant J, McKinney C, Liu RT, Nadorff MR. Distinguishing mediational models and analyses in clinical psychology: atemporal associations do not imply causation. J Clin Psychol. 2016;72:947–55. https://doi.org/10.1002/jclp.2229.

    Article  PubMed  Google Scholar 

  77. Wildes JE, Ringham RM, Marcus M. Emotion avoidance in patients with anorexia nervosa: initial test of a functional model. Int J Eat Disord. 2010;43(5):398–404. https://doi.org/10.1002/eat.20730.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Yook K, Kim KH, Suh SY, Lee KS. Intolerance of uncertainty, worry, and rumination in major depressive disorder and generalized anxiety disorder. J Anxiety Disord. 2010;24(6):623–8. https://doi.org/10.1016/j.janxdis.2010.04.003.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

  1. Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands

    Jojanneke M. Bijsterbosch, Paul A. Boelen, Femke van den Brink, Unna N. Danner & Lot C. Sternheim

  2. Department of Experimental Psychology, Utrecht University, Utrecht, The Netherlands

    Anouk Keizer

  3. ARQ National Psychotrauma Centre, Diemen, The Netherlands

    Paul A. Boelen

  4. ARQ Centrum’45, Diemen, The Netherlands

    Paul A. Boelen

  5. Rintveld Center for Eating Disorders, Altrecht, Zeist, The Netherlands

    Unna N. Danner

Authors
  1. Jojanneke M. Bijsterbosch
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anouk Keizer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Paul A. Boelen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Femke van den Brink
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Unna N. Danner
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lot C. Sternheim
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

JMB and LCS conceived of the presented idea. JMB and UND executed the study. JMB carried out the statistical analyses together with FvdB. JMB wrote the manuscript as part of her Ph.D. project which was supervised by LCS, AK and PAB. All authors discussed the results and contributed to the final manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jojanneke M. Bijsterbosch.

Ethics declarations

Ethical approval and consent to participate

The research protocol was authorized by the Committee Scientific Research of Altrecht Mental Health Institute and the Medical Ethical Committee of the University Medical Center Utrecht. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Consent for publication

All authors have consented in publishing the manuscript.

Competing interests

The authors declare that they have no competing interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bijsterbosch, J.M., Keizer, A., Boelen, P.A. et al. How deep is your thought? The relations between intolerance of uncertainty, worry and weight and shape concerns in adolescent girls with anorexia nervosa. J Eat Disord 9, 164 (2021). https://doi.org/10.1186/s40337-021-00523-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40337-021-00523-4

Keywords

  • Adolescent girls
  • Anorexia nervosa
  • Weight and shape concerns
  • Prospective intolerance of uncertainty
  • Inhibitory intolerance of uncertainty
  • Worry

Journal of Eating Disorders

ISSN: 2050-2974