Qom University of Medical Sciences Journal

Introduction
Generalized anxiety disorder (GAD) is one of the most common anxiety disorders that causes many problems for the people and society. These anxieties includes worries about the future, such as long-term worries about the work or short-term worries about the relationships. Due to the long period of GAD, this disorder has a high negative impact on the social and family life of patients and is associated with a significant decrease in the quality of life. Anxiety becomes a clinical concern when it interferes with the daily life, such that the person has an maladaptive state characterized by severe physical and psychological reactions. People with GAD become helpless due to chronic and severe feelings of anxiety. These feelings are so strong that they become unable to perform their daily activities. Worrying thoughts can cause significant problems in a person's daily functioning. Healthy people are also affected by these thoughts, but their severity and frequency are different. This study aims to predict the improvement in the symptoms of  GAD  based on distress tolerance, tolerance of uncertainty, and cognitive avoidance.
Methods
This a correlational study. Participants were 129 people with GAD in Isfahan, Iran who were selected by sequential sampling method. The inclusion criteria were the diagnosis of GAD based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, age 20-40 years, at least a middle school education, not having other mental or physical disorders that need treatment. Exclusion criteria were: Drug abuse, alcohol consumption, and return of incomplete questionnaires. Data collection tools included the 7-item GAD Questionnaire, distress tolerance scale of Simons and Gaher, Intolerance of Uncertainty Scale of Freeston et al., and cognitive avoidance questionnaire of sexton and dugas. In order to analyze the collected data, Pearson correlation test and stepwise regression analysis were used in SPSS software, version 26.
Results
The majority of participants had age 30-40 years (1.52% in women and 7.65% in men). Most of them were single (45 % in overall; 37 females and 31 males). In the field of education, most of them had bachelor’s degree in overall (31%). Most of females had diploma or bachelor’s degree, while most of males had bachelor’ s degree. The results showed that the improvement of GAD symptoms had a positive significant relationship with distress tolerance (P=0.01) and a negative significant relationship with intolerance of uncertainty (P<0.001). There was no significant relationship between improvement of GAD and cognitive avoidance (P> 0.05).
Discussion
The results showed that tolerance of distress, intolerance of uncertainty, and cognitive avoidance can predict the rate of improvement in GAD. The patients with higher distress tolerance, showed greater improvement in GAD or vice versa. The improvement of GAD had the highest correlation with the predictor variable of intolerance of uncertainty. Cognitive avoidance had weak prediction power. Intolerance of distress and uncertainty and lack of training on cognitive avoidance strategies in patients with GAD can increases their worries about events and tasks in life which can affect their quality of life. Distress tolerance and cognitive avoidance training can reduce their anxiety and increase their performance against problems in life. It is also possible to reduce the severity of GAD by training to balance the mentioned psychological factors so that they can experience a higher quality of life. Overall, it can be concluded that the increase of distress tolerance and decrease of uncertainty intolerance can relive GAD symptoms. The cognitive avoidance had no effect on its improvement.
Ethical Considerations
Compliance with ethical guidelines
The principle of confidentiality of information, information about the results, obtaining informed consent and voluntary withdrawal at each stage of the research were considered for the sample. In order to conduct this research, the code of ethics IR.IAU.KHSH.REC.1400.013 was reviewed and approved at Islamic Azad University, Khomein Yashahr Branch.
Funding
This research is based on Roza Abdullahzadeh's master's thesis in the Department of Psychology, Clinical Psychology, Islamic Azad University, Khomeinishahr Branch, and was carried out at the personal expense of the first author.



Authors contributions
All authors contributed equally in preparing all parts of the research.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
The officials of Farabi Hospital and the Faculty of Humanities of Khomein Yashahr Azad University and the jury of the final paper, who helped the authors in conducting and improving the quality of this research, are thanked and appreciated.