Anxiety sensitivity and intolerance of uncertainty as potential risk factors for cyberchondria

The impact of internet-delivered cognitive behavioural therapy for health anxiety on cyberchondria

Cyberchondria refers to an emotional-behavioural pattern whereby excessive online searches lead to increased anxiety about one's own health status. It has been shown to be associated with health anxiety, however it is unknown whether existing cognitive behavioural therapy (CBT) interventions targeting health anxiety also improve cyberchondria. This study aimed to determine whether internet-delivered cognitive behavioural therapy (iCBT) for severe health anxiety led to improvements in self-reported cyberchondria and whether improvements in cyberchondria were associated with improvements in health anxiety observed during treatment. Methods: We analysed secondary data from a randomised controlled trial (RCT) comparing an iCBT group (n = 41) to an active control group who underwent psychoeducation, monitoring and clinical support (n = 41) in health anxious patients with a DSM-5 diagnosis of Illness Anxiety Disorder and/or Somatic Symptom Disorder. The iCBT group showed a significantly greater reduction in cyberchondria compared to the control group, with large differences at post-treatment on the Cyberchondria Severity Scale Total scale (CSS; Hedges g = 1.09), and the Compulsion, Distress, Excessiveness subscales of the CSS (g's: 0.8-1.13). Mediation analyses showed improvements in health anxiety in the iCBT group were mediated by improvements in all of the CSS subscales, except for the Mistrust subscale. Conclusions: Internet CBT for health anxiety improves cyberchondria.

Recent Insights Into Cyberchondria

PURPOSE OF REVIEW

The construct of cyberchondria was introduced relatively recently. This article aims to review the conceptualization, theoretical basis and correlates of cyberchondria, as well as its prevention and management.

RECENT FINDINGS

Although there is no consensus, most definitions of cyberchondria emphasize online health research associated with heightened distress or anxiety. The two theoretical models of cyberchondria involve reassurance seeking and specific metacognitive beliefs. Cyberchondria has relationships with health anxiety, problematic Internet use and symptoms of obsessive-compulsive disorder, with public health implications pertaining to functional impairment and altered healthcare utilization. Suggestions about prevention and management of cyberchondria have been put forward, but not tested yet. Research interest in cyberchondria has steadily increased. It is uncertain whether cyberchondria can be considered a distinct entity. Future research should aim to clarify the conceptual status of cyberchondria, quantify its impact and develop evidence-based approaches for a better control of cyberchondria.

What are the Implications of Excessive Internet Searches for Medical Information by Orthopaedic Patients?

BACKGROUND

Cyberchondria may be defined as heightened distress evoked through excessive searches of the internet for medical information. In healthy people, cyberchondria is associated with a greater intolerance of uncertainty and greater health anxiety. These relationships are likely bidirectional. People who have a greater intolerance of uncertainty may be more likely to search the internet for medical information and have greater health anxiety. This greater health anxiety may lead to an increased likelihood of engaging in further internet searches and greater intolerance of uncertainty. These three constructs are important for patients because they impact patient function and health care costs. We were specifically interested in understanding the role of cyberchondria in the association between intolerance of uncertainty and health anxiety among orthopaedic patients because it has not been explored before and because knowledge about these interactions could inform treatment recommendations.

QUESTIONS/PURPOSES

Does cyberchondria mediate (that is, explain) the association between intolerance of uncertainty and health anxiety in orthopaedic patients searching for medical information on the internet, after controlling for potentially confounding variables?

METHODS

This was a cross-sectional study of 104 patients who had searched the internet for any medical information about their current condition. A research assistant approached 155 patients attending two orthopaedic outpatient clinics, one hand and upper extremity service and one sports medicine clinic, during a 3-month period. Ten patients declined to participate and 41 patients were excluded, predominantly because they had never searched for medical information online. The patients completed the Cyberchondria Severity Scale, Intolerance of Uncertainty Scale-short version, Short Health Anxiety Inventory, and a numerical rating scale for pain intensity at baseline, as well as demographic and clinical questionnaires. We performed a series of linear regression analyses to determine whether a greater intolerance of uncertainty predicts greater cyberchondria (mediator) and whether cyberchondria predicts greater health anxiety. Although it is more appropriate to use the language of association (such as "whether cyberchondria is associated with health anxiety") in many observational studies, here, we opted to use the language of causation because this is the conventional language for studies testing statistical mediation.

RESULTS

After controlling for potentially confounding variables including pain intensity, multiple pain conditions, and education, cyberchondria explained 33% of the variance of the effect of intolerance of uncertainty on health anxiety (95% CI, 6.98 to 114.72%; p < 0.001).

CONCLUSIONS

Among orthopaedic patients who search the internet for medical information, a greater intolerance of uncertainty is associated with greater cyberchondria, which is associated with greater anxiety about health. Identifying patients with an intolerance of uncertainty and educating them about the negative role of compulsive searches for medical information may improve the success of orthopaedic treatment. Orthopaedic surgeons should also consider making referrals for cognitive behavioral therapy in these instances to increase the patient's tolerance of uncertainty, decrease internet searching habits, and reduce anxiety about health.

LEVEL OF EVIDENCE

Level III, prognostic study.

Psychometric properties of the Iranian version of the Anxiety Sensitivity Index-3 (ASI-3)

INTRODUCTION

Anxiety sensitivity plays a prominent role in the etiology of anxiety disorders. This construct has attracted widespread interest from experts and researchers. The Anxiety Sensitivity Index (ASI-3) is the most common scale for measuring anxiety sensitivity.

OBJECTIVE

To analyze the psychometric properties and factor structure of the ASI-3 in Iranian student samples.

METHODS

220 students (135 women, 85 men) from Kermanshah University of Medical Sciences were selected by the convenience sampling method to evaluate the psychometric properties and analyze the factor structure of the ASI-3. The subjects were also asked to complete the Acceptance and Action Questionnaire-II (AAQ-II), Whiteley Index, Intolerance of Uncertainty, and Neuroticism scales. LISREL and SPSS were used to analyze the data. Cronbach's alpha and correlation coefficients were calculated and confirmatory factor analysis was conducted.

RESULTS

The results of the confirmatory factor analysis revealed a three-factor structure with physical, cognitive, and social components (comparative fit index = 0.94; normed fit index = 0.91; root mean square error of approximation = 0.09). The ASI-3 had positive and significant correlations with health anxiety (0.59), intolerance of uncertainty (0.29), and neuroticism (0.51). Furthermore, the ASI-3 had a negative and significant correlation with the AAQII (-0.58). Cronbach's alpha coefficients for the whole scale and for the physical, cognitive, and social concerns factors were 0.90, 0.74, 0.79, and 0.78, respectively. The invariance of the index was significant compared to the original English version.

CONCLUSION

In general, the results support the adequacy of the psychometric properties of the Persian version of the ASI-3. Theoretical and applied implications will be discussed.

Cyberchondria and its Relationships with Related Constructs: a Network Analysis

Cyberchondria denotes repeated online searches for health information that are associated with increasing levels of health anxiety. The aims of this study were to apply network analysis to investigate the extent to which cyberchondria is a distinct construct, ascertain which of the related constructs have the strongest relationships with cyberchondria and investigate whether some of the symptoms of cyberchondria are more central to the construct of cyberchondria. Questionnaires assessing the severity of cyberchondria, health anxiety, obsessive-compulsive disorder symptoms, intolerance of uncertainty, problematic Internet use, anxiety, depression and somatic symptoms were administered to 751 participants who searched for health information online during a previous 3-month period and were recruited from an online crowdsourcing platform. Network analyses were used to compute the networks, perform community detection tests and calculate centrality indices. Results suggest that cyberchondria is a relatively specific syndrome-like construct, distinct from all related constructs and consisting of interrelated symptoms. It has the strongest relationships with problematic Internet use and health anxiety. No symptom of cyberchondria emerged clearly as more central to the construct of cyberchondria. Future research should aim to deepen our understanding of cyberchondria and its links with psychopathology, especially its close relationship with problematic Internet use.

The relationships between health anxiety, online health information seeking, and cyberchondria: Systematic review and meta-analysis

BACKGROUND

Cyberchondria refers to an abnormal behavioral pattern in which excessive or repeated online searches for health-related information are distressing or anxiety-provoking. Health anxiety has been found to be associated with both online health information seeking and cyberchondria. The aims of the present systematic review and meta-analysis were to examine the magnitude of these associations and identify any moderator variables.

METHODS

A systematic literature search was performed across several databases (PsycINFO, PubMed, Embase) and reference lists of included studies.

RESULTS

Twenty studies were included across two independent meta-analyses, with 7373 participants. Random effects meta-analyses showed that there was a positive correlation between health anxiety and online health information seeking [r = 0.34, 95% CI (0.20, 0.48), p < .0001], and between health anxiety and cyberchondria [r = 0.62, 95% CI (0.52, 0.71), p < .0001]. A meta-regression indicated that the age of study participants [Q(1) = 4.58, p = .03] was partly responsible for the heterogeneity found for the relationship between health anxiety and cyberchondria.

LIMITATIONS

The generalizability and validity of our findings are restricted by the methodological limitations of the primary studies, namely, an over-reliance on a single measure of cyberchondria, the Cyberchondria Severity Scale.

CONCLUSIONS

Our review found a positive correlation between health anxiety and online health information seeking, and between health anxiety and cyberchondria. Further research should aim to explore the contexts for these associations as well as address the identified limitations of the extant literature.

Moving toward a metacognitive conceptualization of cyberchondria: Examining the contribution of metacognitive beliefs, beliefs about rituals, and stop signals

Cyberchondria refers to the repeated use of the Internet to search for health information that leads to negative consequences. The present set of studies examined the tenability of a proposed metacognitive conceptualization of cyberchondria that includes metacognitive beliefs about health-related thoughts, beliefs about rituals, and stop signals. The contribution of those variables to cyberchondria was examined among 330 undergraduate students from a U.S. university in Study 1 and 331 U.S. community respondents in Study 2. All participants reported using the Internet to search for health information. Across both studies, metacognitive beliefs, beliefs about rituals, and stop signals shared positive bivariate associations with cyberchondria and accounted for unique variance in cyberchondria scores in multivariate analyses. Beliefs about rituals and stop signals emerged as relatively specific to cyberchondria versus health anxiety in multivariate analyses. Results provide preliminary support for a metacognitive conceptualization of cyberchondria, with extensions of the present findings discussed.

The potential use of social media and other internet-related data and communications for child maltreatment surveillance and epidemiological research: Scoping review and recommendations

Collecting child maltreatment data is a complicated undertaking for many reasons. As a result, there is an interest by child maltreatment researchers to develop methodologies that allow for the triangulation of data sources. To better understand how social media and internet-based technologies could contribute to these approaches, we conducted a scoping review to provide an overview of social media and internet-based methodologies for health research, to report results of evaluation and validation research on these methods, and to highlight studies with potential relevance to child maltreatment research and surveillance. Many approaches were identified in the broad health literature; however, there has been limited application of these approaches to child maltreatment. The most common use was recruiting participants or engaging existing participants using online methods. From the broad health literature, social media and internet-based approaches to surveillance and epidemiologic research appear promising. Many of the approaches are relatively low cost and easy to implement without extensive infrastructure, but there are also a range of limitations for each method. Several methods have a mixed record of validation and sources of error in estimation are not yet understood or predictable. In addition to the problems relevant to other health outcomes, child maltreatment researchers face additional challenges, including the complex ethical issues associated with both internet-based and child maltreatment research. If these issues are adequately addressed, social media and internet-based technologies may be a promising approach to reducing some of the limitations in existing child maltreatment data.

Willingness to Seek Treatment Among Black Students With Anxiety or Depression: The Synergistic Effect of Sociocultural Factors With Symptom Severity and Intolerance of Uncertainty

Anxiety and depressive disorders are among the most commonly diagnosed psychiatric disorders, yet they remain largely undertreated in the U.S. and Black adults are especially unlikely to seek or receive mental health services. Symptom severity has been found to impact treatment-seeking behaviors as have sociocultural factors. Yet no known research has tested whether these factors work synergistically to effect willingness to seek treatment. Further, emerging data point to the importance of transdiagnostic risk factors such as intolerance of uncertainty (IU). IU may be negatively related to seeking treatment given that Black adults may be uncertain whether treatment might benefit them. Thus, the current study examined the relations between symptom severity/IU and willingness to seek treatment for anxiety/depression problems and the impact of key sociocultural variables (i.e., cultural mistrust-interpersonal relations [CMI-IR], perceived discrimination [PED]) on these relations among 161 (85% female) Black undergraduates. Consistent with prediction, symptom severity was positively related to willingness, but unexpectedly, IU was positively related. There was a significant Symptom Severity × CMI-IR interaction such that severity was positively related to willingness among students with lower cultural mistrust, but not higher mistrust. There were also significant IU × PED interaction such that IU was positively related to willingness among students with lower PED, but not higher PED. Results highlight the importance of considering the interplay between symptom severity, transdiagnostic vulnerability factors, and sociocultural variables when striving to identify factors related to treatment seeking behaviors among anxious and/or depressed Black students.

Mapping of Crowdsourcing in Health: Systematic Review

Background

Crowdsourcing involves obtaining ideas, needed services, or content by soliciting Web-based contributions from a crowd. The 4 types of crowdsourced tasks (problem solving, data processing, surveillance or monitoring, and surveying) can be applied in the 3 categories of health (promotion, research, and care).

Objective

This study aimed to map the different applications of crowdsourcing in health to assess the fields of health that are using crowdsourcing and the crowdsourced tasks used. We also describe the logistics of crowdsourcing and the characteristics of crowd workers.

Methods

MEDLINE, EMBASE, and ClinicalTrials.gov were searched for available reports from inception to March 30, 2016, with no restriction on language or publication status.

Results

We identified 202 relevant studies that used crowdsourcing, including 9 randomized controlled trials, of which only one had posted results at ClinicalTrials.gov. Crowdsourcing was used in health promotion (91/202, 45.0%), research (73/202, 36.1%), and care (38/202, 18.8%). The 4 most frequent areas of application were public health (67/202, 33.2%), psychiatry (32/202, 15.8%), surgery (22/202, 10.9%), and oncology (14/202, 6.9%). Half of the reports (99/202, 49.0%) referred to data processing, 34.6% (70/202) referred to surveying, 10.4% (21/202) referred to surveillance or monitoring, and 5.9% (12/202) referred to problem-solving. Labor market platforms (eg, Amazon Mechanical Turk) were used in most studies (190/202, 94%). The crowd workers’ characteristics were poorly reported, and crowdsourcing logistics were missing from two-thirds of the reports. When reported, the median size of the crowd was 424 (first and third quartiles: 167-802); crowd workers’ median age was 34 years (32-36). Crowd workers were mainly recruited nationally, particularly in the United States. For many studies (58.9%, 119/202), previous experience in crowdsourcing was required, and passing a qualification test or training was seldom needed (11.9% of studies; 24/202). For half of the studies, monetary incentives were mentioned, with mainly less than US $1 to perform the task. The time needed to perform the task was mostly less than 10 min (58.9% of studies; 119/202). Data quality validation was used in 54/202 studies (26.7%), mainly by attention check questions or by replicating the task with several crowd workers.

Conclusions

The use of crowdsourcing, which allows access to a large pool of participants as well as saving time in data collection, lowering costs, and speeding up innovations, is increasing in health promotion, research, and care. However, the description of crowdsourcing logistics and crowd workers’ characteristics is frequently missing in study reports and needs to be precisely reported to better interpret the study findings and replicate them.

Cyberchondria: Overlap with health anxiety and unique relations with impairment, quality of life, and service utilization

Cyberchondria refers to a clinical phenomenon in which repeated Internet searches regarding medical information result in excessive concerns about physical health. Cyberchondria is positively associated with symptoms of health anxiety, though it remains unclear as to whether cyberchondria poses a unique public burden. The current study replicated previous findings regarding the relationship between cyberchondria and health anxiety, and extended those findings to examine the extent to which health anxiety and cyberchondria may be differentially associated with public health outcomes, including impairment, quality of life, and service utilization. Community participants (N = 462) recruited via online crowdsourcing completed a battery of self-report questionnaires assessing cyberchondria, health anxiety, and measures of public health outcomes, including the WHOQOL and SDS. Bifactor latent variable modeling indicated that cyberchondria was closely related to, yet importantly distinct from, health anxiety. Moreover, when accounting for overlap with health anxiety, cyberchondria was associated with increased functional impairment and healthcare utilization. Results provide further support for the identification of cyberchondria as a distinct set of clinical symptoms that may pose a significant public health burden. Future research should determine ways in which to treat and/or prevent symptoms.

Cyberchondria: Examining relations with problematic Internet use and metacognitive beliefs

Cyberchondria refers to the repeated use of the Internet to search for health-related information, which leads to negative consequences. This two-part study provides the first known examination of how cyberchondria relates to (a) problematic Internet use and (b) metacognitive beliefs. Participants were U.S. community adults who reported using the Internet to search for health-related information (Study 1: N = 337, Study 2: N = 260). In Study 1, cyberchondria shared a strong association with problematic Internet use, and that association was unaccounted for by age, gender, current reported medical status, negative affect, or health anxiety. In Study 2, cyberchondria was found to share moderate to strong associations with metacognitive beliefs. The association between cyberchondria and metacognitive beliefs about the uncontrollability of thoughts remained intact after accounting for the Study 1 covariates, as well as anxiety sensitivity and intolerance of uncertainty. Neither anxiety sensitivity nor intolerance of uncertainty shared unique associations with cyberchondria. These results provide a preliminary indication that a metacognitive conceptualization of problematic Internet use may be applicable to cyberchondria.

[Digital media as laypeople's source of information about the environment and health]

Over the last two decades, the Internet has become the primary source of information. Thanks to the Internet, laypeople have access to information from the health and the environmental sector, which was for a long time available only to experts (e. g. scientific publications, statistics). Information on the Internet varies in quality, as generally anybody can publish online, without any quality control. At the same time, Internet use comes with specific situational characteristics. Given that the amount of information is nearly unlimited and that this information is easily available via search engines, users are not restricted to one or just a few texts, but can choose between multiple sources depending on their motivation and interest. Together with the heterogeneity of the sources, this provides the basis for a strong impact of motivation on the process and the outcomes of information acquisition online. Based on empirical research in the domain of Internet searching in the health sector, the current article discusses the impact of the use of digital media in the context of environmental medicine. Research has led to four conclusions: (1) Users are not sufficiently sensitive to the quality of information. (2) Information supporting their own opinion is preferably processed. (3) Users who feel threatened focus on positive information. (4) Vigilant users focus on negative information, which might result in cyberchrondria. The implications of these effects for the use of digital media in the sector of environmental medicine are discussed.

Does cyberchondria overlap with health anxiety and obsessive-compulsive symptoms? An examination of latent structure and scale interrelations

Searching for medical information online is a widespread activity that increases distress for many individuals. Researchers have speculated that this phenomenon, referred to as cyberchondria, overlaps substantially with both health anxiety and obsessive-compulsive symptoms. This study sought to examine: (1) the distinguishability of cyberchondria from health anxiety and obsessive-compulsive symptoms and (2) the components of health anxiety and obsessive-compulsive symptoms that cluster most strongly with cyberchondria. The sample consisted of community adults in the United States with no current reported medical problems (N=375). Results from confirmatory factor analyses (CFAs) support the idea that cyberchondria is distinct from, yet related to, health anxiety and obsessive-compulsive symptoms. Results from zero-order correlations and regression analyses suggest that cyberchondria clusters with the affective (health worry) component of health anxiety. Regression results diverged from prior findings, as obsessive-compulsive symptoms did not share associations with cyberchondria after accounting for negative affect and health anxiety. The present results indicate that cyberchondria is possibly discernible from both health anxiety and obsessive-compulsive symptoms, while also providing insight into areas of potential overlap.

Relationships between cyberchondria and obsessive-compulsive symptom dimensions

Researchers have recently begun to investigate a vicious cycle of escalating physical health concerns and online medical information seeking coined "cyberchondria". Research has shown that cyberchondria is strongly associated with health anxiety (HA), but there is a dearth of work investigating the potential relationships between cyberchondria and other anxiety-related pathologies. One such condition is obsessive-compulsive disorder (OCD), which could theoretically be related to cyberchondria given the physical health relevant focus of certain types of OC symptoms. The current study sought to investigate the potential relationship between cyberchondria OCD across OC symptom dimensions. Community participants (N=468) were recruited via online crowdsourcing to complete a battery of self-report questionnaires including cyberchondria and OC measures. Structural equation modeling revealed significant unique associations between both contamination/washing and responsibility for harm/checking symptoms, and cyberchondria, such that greater cyberchondria was associated with greater OC symptoms after controlling for HA and trait negative affect. These results suggest that similar to proposed models of cyberchondria and HA, cyberchondria could potentially play a role in the development/maintenance of two dimensions of OC symptoms, or vice versa. Future work will need to determine the causal nature of these relationships or whether they are simply co-occurring phenomena.

Anxiety sensitivity and intolerance of uncertainty as potential risk factors for cyberchondria: A replication and extension examining dimensions of each construct

BACKGROUND

Preliminary findings suggest that anxiety sensitivity (AS) and intolerance of uncertainty (IU) may confer vulnerability for cyberchondria, defined as repeated internet searches for medical information that exacerbates health anxiety. Prior studies are limited because it remains unclear whether specific AS or IU dimensions differentially relate to certain cyberchondria dimensions.

METHODS

The present study examined associations among AS, IU, and cyberchondria dimensions using a sample of community adults (N = 578) located in the United States.

RESULTS

As predicted, physical AS and inhibitory IU were the only AS or IU dimensions to share unique associations with the distress cyberchondria dimension after controlling for the overlap among the AS dimensions, IU dimensions, and health anxiety. Cognitive AS and social AS unexpectedly evidenced unique associations with cyberchondria dimensions.

LIMITATIONS

The results are limited by the cross-sectional study design and use of a community, rather than clinical, sample.

CONCLUSIONS

This study provides evidence that specific AS and IU dimensions may confer vulnerability to certain cyberchondria dimensions. Further clarifying associations among AS, IU, and cyberchondria may lead to improvements in our conceptualization and, ultimately, treatment of cyberchondria.

Validation of the Cyberchondria Severity Scale (CSS): replication and extension with bifactor modeling

Internet help seeking behaviors are increasingly common. Despite the positives associated with technology, cyberchondria, or the process of increased anxiety in response to internet medical information seeking, is on the rise. The Cyberchondria Severity Scale (CSS) was recently developed to provide a valid measure of cyberchondria across multiple dimensions. The current study sought to extend previous work on the CSS factor structure by examining a bifactor model. Participants (N=526) from a community sample completed the CSS via online crowd sourcing. Results revealed that the bifactor model of the CSS provided superior fit to the data, suggesting that it is useful to conceptualize the CSS as containing a General Cyberchondria factor that is orthogonal to its subfactors. Similar to previous work, the CSS Mistrust factor does not appear to be necessary to this construct. Finally, results revealed unique relations between General and Specific Cyberchondria factors with lower-order health anxiety dimensions.