Editorial

Psychother Psychosom 2017;86:129–133 Received: January 14, 2017

Accepted after revision: February 25, 2017
DOI: 10.1159/000465525
Published online: May 11, 2017

Cyberchondria: Challenges of
Problematic Online Searches for
Health-Related Information
Vladan Starcevic
Sydney Medical School, University of Sydney, and Department of Psychiatry, Nepean Hospital, Sydney, NSW, Australia

The digital revolution has changed many aspects of for health-related information and anxiety about health
life, for example, the way in which health-related infor- [2]. The direction of causality in the relationship between
mation is obtained. Such information is now very easy to online health-related searches and health anxiety may
access via the Internet, at little or no cost. For most peo- vary from one individual to another. In some cases, per-
ple, the Internet has become the first stop when they need haps a majority, a heightened health anxiety is primary
to find out more about symptoms, health and disease. The and attempt to alleviate it is the reason for online health-
consequences of this change are being increasingly ap- related searches; however, these searches only cause more
preciated, but they are still poorly understood. While distress and make health anxiety worse [3–7]. In others
some people feel empowered by an easy access to health who develop elevated levels of health anxiety after online
information and less anxious after seeking health infor- health-related searches, there is no history of heightened
mation on the Internet, others are more anxious or puz- health anxiety or hypochondriasis and their motivation
zled [1]. This is likely to affect health care-seeking behav- for performing searches may be different (e.g., curiosity
iour and relationship with physicians. or appearance of a new symptom) [8–10]. It is important
to note that regardless of what occurs first (health anxiety
or online health-related searches), online health-related
What Is Cyberchondria? searches in cyberchondria result in higher levels of health
anxiety compared to the levels of health anxiety prior to
The concept of cyberchondria has been invoked to re- initiating these searches.
fer to the anxiety-amplifying effects of online health-re- Taking into account these considerations, it can be
lated searches. Considering the origin of the term (i.e., as proposed that cyberchondria denotes repeated online
the counterpart of hypochondria in the digital age), cy- searches for health-related information that are associ-
berchondria refers to an abnormal behavioural pattern ated with increasing levels of health anxiety. Health anxi-
and emotional state. In other words, cyberchondria is not ety is conceptualised here in accordance with the revised
just a tendency to seek health-related information on the version of the Diagnostic Criteria for Psychosomatic Re-
Internet, which has become a normal part of modern life. search (DCPR) as a “generic worry about illness” [11].
Several definitions of cyberchondria have been proposed This definition of cyberchondria primarily refers to the
and they all include excessive or repeated online searches specific behaviour – online health-related searches; it

© 2017 S. Karger AG, Basel Vladan Starcevic

Department of Psychiatry, Nepean Hospital
PO Box 63
E-Mail [email protected]
Penrith, NSW 2751 (Australia)
www.karger.com/pps
E-Mail vladan.starcevic @ sydney.edu.au
does not suggest that cyberchondria is a distinct condi- sense of uncertainty about one’s health may increase dur-
tion, much less an independent diagnostic entity. Also, it ing online health-related searches, especially when online
would be misleading to conceptualise cyberchondria information is ambiguous or conflicting; a need to quell
solely as a modern “version” of hypochondriasis, a condi- that uncertainty and arrive at a “closure” may then drive
tion that contrary to DSM-5, continues to be recognised further online searches. Likewise, if the Internet is per-
as a distinct disorder by the revised version of the DCPR ceived as the best medium to provide a “perfect” explana-
[11]. While high levels of health anxiety have been associ- tion for any health-related query because it contains in-
ated with more Internet use to search for health-related formation on “everything,” this may fuel further online
information [4, 5, 12, 13], whereby online health-related searches. Selective attention paid to health-related infor-
searches usually serve the purpose of reassurance seeking mation found online may contribute to an increase in
or checking in the context of pre-existing hypochondria- health anxiety and motivate some people to keep coming
sis, people without pre-existing hypochondriasis may back to the Internet to reduce anxiety by continuing the
also become excessively anxious about their health as a searches.
result of these searches, as noted above. What appears to Anxiety-amplifying factors pertain to various aspects
be shared by all individuals with cyberchondria is exces- of the online environment in which health-related search-
sive amount of time spent performing the searches. This es take place. In such an environment, it may be more
is usually at the expense of participating in other activi- difficult to distinguish between credible and non-credible
ties, which can have further negative consequences. sources of information than in an offline, “real” world.
The Cyberchondria Severity Scale [7] was developed to Because of this, information obtained via unregulated
measure the severity of cyberchondria. This instrument (potentially less trustworthy) websites may be treated in
conceptualises cyberchondria as a multidimensional con- the same way as information found on the “official” (po-
struct consisting of compulsion (unwanted nature of tentially more trustworthy) websites, producing confu-
online health-related searches), distress (negative emotion- sion and anxiety if there is a discrepancy in their content
al states and physiological reactions associated with on- [19]. Furthermore, the Internet is not designed to always
line health-related searches), excessiveness, reassurance provide relevant, accurate, non-conflicting, non-ambig-
(seeking reassurance from a medical professional) and uous or reassuring information, which makes the out-
mistrust of medical professionals (conflict as to whether come of online health-related searches less predictable
one should trust one’s own doctor or results of online compared to the outcome of seeking reassurance from a
searches). family member or physician [6]. Not only can the Inter-
net provide conflicting, ambiguous or wrong information
on the subject of the search, but it can be distracting and
What May Be Specific for Cyberchondria? lead to other, potentially anxiety-amplifying information
(e.g., information about hitherto unknown diseases or
If the proposed definition of cyberchondria is correct, health risks). Some people may not realise that the Inter-
it is crucial to understand both how online health-related net is not an ideal place to seek reassurance, with a failure
searches increase health anxiety and why this behavioural to obtain the expected reassurance in the course of online
pattern continues despite its adverse effects. In this re- health-related searches increasing their health anxiety.
gard, the factors that are associated with hypochondriasis Other anxiety-amplifying factors boil down to various
(“associated factors”), some of which may also play a role difficulties with managing online information, especially
in cyberchondria, need to be distinguished from the fac- online health information. It has been suggested that
tors that amplify health anxiety during online searches health anxiety may increase because of the erroneous be-
(“anxiety-amplifying factors”). This is because the latter liefs about the ranking of search results, that is, a tenden-
may be specific for cyberchondria. cy to equate higher rankings of online search results with
Among others, the associated factors include intoler- higher probabilities of providing an explanation [3].
ance of uncertainty [14], need for thorough, “perfect” ex- Thus, an interpretation of the higher ranking of some ma-
planations of symptoms and other health complaints [15, lignancy as an explanation for the symptom that initiated
16] and selective attention to and perception of health- an online search is very likely to increase health anxiety.
related information [17, 18]. These factors may also act to Another anxiety-amplifying factor may be a difficulty
maintain cyberchondria, thereby explaining the repeti- managing abundant online information about health, es-
tiveness of online health-related searches. For example, a pecially if it is conflicting or vague [6, 9]. Information

130 Psychother Psychosom 2017;86:129–133 Starcevic

DOI: 10.1159/000465525
overload is known to generate distress and anxiety [20] that online health information should be avoided carries
and some individuals who embark on an online health- a message that such information is inherently threaten-
related search are surprised to find out that “more” does ing, which may be more likely to perpetuate cyberchon-
not necessarily mean “better,” as they do not expect abun- dria than to reduce it. Second, it seems unrealistic to sug-
dance of information to increase their health anxiety. gest “abstinence” from any innocuous Internet-related
Similar to the associated factors, anxiety-amplifying activity in an era that is already heavily Internet-reliant
factors can also play a role in maintaining cyberchondria. and likely to be even more so in the future. That is, people
Thus, difficulties in distinguishing between credible and cannot afford to ignore the Internet as the primary source
non-credible sources of online information, expectations of health-related information.
that the Internet will ultimately provide reassurance, on- Instead of promoting the notion that staying away
line anxiety-amplifying distractions and difficulties with from online health information is salubrious, treatment
interpreting and managing online health information are approaches to cyberchondria should have two main goals:
likely to drive further online searches. For this reason, (1) enabling people to use the Internet for health-related
anxiety-amplifying factors need to be targeted by any ef- purposes without experiencing a heightened health anxi-
fort to decrease or eliminate cyberchondria. To the extent ety; (2) reducing the time spent online for health-related
that some associated factors play a role in cyberchondria, purposes so that other activities would not be neglected
especially in the context of hypochondriasis, they should and functioning could improve. Reaching these goals will
be addressed as well. be possible if people are exposed to health-related online
material in a gradual, controlled fashion, if they learn that
online health information is not inherently threatening
Management Implications or overwhelming, if they become confident that they can
manage such information and if they can control any urg-
Several “technical” issues can be addressed to decrease es to make extensive and unnecessary online health-relat-
the likelihood of developing cyberchondria. This involves ed searches.
the ways in which online health information and results Treatment of cyberchondria should be a part of the
of online health-related searches are presented. For ex- comprehensive management of individuals with hypo-
ample, a clear and user-friendly presentation of online chondriasis if cyberchondria is only one aspect of hypo-
health information is likely to decrease the misinterpreta- chondriasis. In the absence of hypochondriasis, efforts to
tion and escalation of health anxiety, as is the ranking of address the associated, anxiety-amplifying and maintain-
the results of online searches based on true probabilities ing factors should still be made. This requires a careful
in the relationships between the specific symptoms and case formulation identifying these factors in every indi-
diagnoses [3]. Even with these improvements, the risk of vidual, as well as the specific precipitants (e.g., appear-
cyberchondria cannot be entirely eliminated. Regardless ance of a new symptom), function that cyberchondria
of the manner in which information about serious and serves (e.g., reassurance seeking) and its consequences
life-threatening diseases is conveyed, the unpleasant or (e.g., neglecting family responsibilities as a result of the
potentially fear-eliciting content of such information will time spent performing online health-related searches and
always remain. Also, disagreements between different the associated distress).
sources of online information cannot be resolved by im- Regardless of the specific factors, psychoeducation
proving the clarity of that information. In light of this, about cyberchondria seems to be an essential part of any
what therapeutic recommendations can be given to indi- treatment package. This involves improving online health
viduals with cyberchondria? information literacy that focuses on several issues: (1)
One study suggests that patients with “moderate-se- what the Internet can and cannot do; (2) distinguishing
vere health anxiety” should avoid using the Internet for between credible and non-credible sources of online
health-related information based on a strong association health information; (3) appraising the results of online
between health anxiety and cyberchondria [21]. A similar health searches critically.
recommendation was implicitly made on the grounds First and foremost, individuals with cyberchondria
that online health-related searches primarily serve the need to learn that the Internet is only a means of obtain-
function of reassurance seeking, thereby maintaining hy- ing health-related information and that it is not an om-
pochondriasis [19]. However, this recommendation is nipotent agent that delivers reassurance reliably or has
problematic for at least two reasons. First, a suggestion answers for all health-related questions. Also, the Internet

Cyberchondria Psychother Psychosom 2017;86:129–133 131

DOI: 10.1159/000465525
is not a tool for self-diagnosis, despite a temptation to use congruity between different sources of health informa-
it as such. Individuals with cyberchondria would benefit tion whenever they try to make sense of the results of their
from learning that accumulating information about one’s online health searches. This endeavour necessitates a ca-
symptoms as a result of online health searches is not tan- pacity to tolerate the resultant increase in uncertainty, but
tamount to establishing a diagnosis that explains those it also fosters critical and realistic thinking. In the end,
symptoms. A finding that online health-related searches such thinking leads to better outcomes than jumping to
by individuals with high levels of health anxiety are asso- simple, but catastrophic conclusions about one’s symp-
ciated with a greater likelihood of visiting a physician [4, toms.
5, 12, 13] suggests that such searches are not sufficient.
Consequently, Internet-derived self-diagnosis should not
be the aim of online health-related searches, even when Outlook for the Future
online “symptom checkers” with diagnostic algorithms
are used. Cyberchondria is a fascinating example of how the
Knowing which health websites are reliable and trust- digital technology may play an important, though not an
worthy and which are not is not as simple as it may seem. exclusive role, in causing psychopathological phenome-
Attempts to categorise health websites on the basis of na. It also points to the novel ways in which people with
their quality have apparently been met with much resis- hypochondriasis, a condition known for centuries, can
tance and there are no clear criteria or guidelines in this present. Whether these are two essentially different clini-
area. The usual suggestion to give more weight to govern- cal presentations or conditions is unknown. Therefore, a
ment websites, those that clearly state names of the au- need to better understand the aetiological links and path-
thors and their credentials, websites that have no financial ways in the relationships between hypochondriasis,
interests and belong to reputable academic, medical or health anxiety and online health-related searches cannot
scientific organisations and sources that frequently up- be overemphasised.
date their content and provide scientific evidence and ref- Research on cyberchondria is in its infancy. Most of
erences to support their statements or recommendations the studies thus far have used a cross-sectional design and
[22] may be helpful only to a certain extent. This is be- have been conducted in relatively small, non-clinical
cause some people are generally mistrustful or even re- samples, raising concerns about their representativeness.
sentful of any official institution and may trust more what Other issues are a lack of agreement about the concept of
they find on the websites of support groups run by pa- cyberchondria and problems with the only assessment
tients and the corresponding discussion forums and bul- tool developed thus far, the Cyberchondria Severity Scale
letin boards. Mistrust of physicians is certainly an issue [7]. This instrument has been criticised for being too
for many individuals with hypochondriasis and high lev- broad, encompassing items that are not necessarily rele-
els of health anxiety [13, 23, 24], while negative expecta- vant or specific for cyberchondria and giving cyberchon-
tions of healthcare professionals have been found to drive dria almost a status of a disorder, with its subscales and
seeking of health information online [19]. More often dimensions resembling the diagnostic criteria [2]. The
than not, people performing online health-related search- Cyberchondria Severity Scale also has some psychometric
es end up comparing several sources of health informa- deficiencies in that its original five-factor structure could
tion as they try to get answers to their queries. If there is not be confirmed, with a suggestion that one of its sub-
a discrepancy between these sources, knowing whom to scales, mistrust of medical professionals, should be omit-
trust becomes a guessing game, which is often the pre- ted [25–27]. All this calls for the development of a refined
dicament of individuals with cyberchondria. This is why assessment tool for cyberchondria and longitudinal, pro-
it is important not only to educate such individuals how spective studies conducted in various populations, in-
to distinguish credible from non-credible sources of cluding clinical samples.
health information (as much as that is possible), but also Waiting for a conceptual consensus on cyberchondria
address the issue of trust more broadly. and better understanding of it in order to develop treat-
In a complex area such as health and illness, different ments for cyberchondria would be irresponsible. There
opinions and disagreements are more a rule than excep- are measures that can be taken to help individuals who
tion, which may be difficult for individuals with cyber- are distressed or feel overwhelmed by anxiety when con-
chondria to accept. Therefore, they need to be taught to ducting online health-related searches. At present, these
take into account this complexity and the attendant in- measures are not evidence-based, but they can serve as

132 Psychother Psychosom 2017;86:129–133 Starcevic

DOI: 10.1159/000465525
the basis for developing treatment approaches that would Disclosure Statement
be tested in randomised, controlled studies. Finally, it is
The author does not have any conflict of interest to declare.
prudent to recommend that all physicians routinely ask
patients about their online health-related searches and
impact that these searches have on their well-being and
help-seeking behaviour.

References
1 White RW, Horvitz E: Experiences with Web 10 Te Poel F, Baumgartner SE, Hartmann T, Ta- 20 Rao P, Skoric MM: Web searching for health:
search on medical concerns and self diagno- nis M: The curious case of cyberchondria: a theoretical foundations for analyzing prob-
sis; in Proceedings from the American Medi- longitudinal study on the reciprocal relation- lematic search engine use; in Datta A, Shul-
cal Informatics Association Annual Sympo- ship between health anxiety and online health man S, Zheng B, Lin SD, Sun A, Lim EP (eds):
sium 2009 (AMIA 2009). Red Hook, Curran information seeking. J Anxiety Disord 2016; Social Informatics. Third International Con-
Associates, 2009, pp 696–700. 43:32–40. ference, SocInfo 2011, Singapore, October
2 Starcevic V, Berle D: Cyberchondria: an old 11 Fava GA, Cosci F, Sonino N: Current psycho- 2011. Proceedings. Lecture Notes in Comput-
phenomenon in a new guise? in Aboujaoude somatic practice. Psychother Psychosom er Science (LNCS) 6984. Berlin, Springer-
E, Starcevic V (eds): Mental Health in the Dig- 2017;86:13–30. Verlag, 2011, pp 59–66.
ital Age: Grave Dangers, Great Promise. New 12 Eastin MS, Guinsler NM: Worried and wired: 21 Doherty-Torstrick ER, Walton KE, Fallon
York, Oxford University Press, 2015, pp 106– effects of health anxiety on information-seek- BA: Cyberchondria: parsing health anxiety
117. ing and health care utilization behaviors. Cy- from online behavior. Psychosomatics 2016;
3 White RW, Horvitz E: Cyberchondria: studies berpsychol Behav 2006;9:494–498. 57:390–400.
of the escalation of medical concerns in Web 13 Singh K, Brown RJ: Health-related Internet 22 Reavley NJ, Jorm AF: Psychoeducation and
search. ACM Trans Inform Syst 2009; 27:ar- habits and health anxiety in university stu- the Internet; in Aboujaoude E, Starcevic V
ticle 23. dents. Anxiety Stress Coping 2014; 27: 542– (eds): Mental Health in the Digital Age: Grave
4 Baumgartner SE, Hartmann T: The role of 554. Dangers, Great Promise. New York, Oxford
health anxiety in online health information 14 Boelen PA, Carleton RN: Intolerance of un- University Press, 2015, pp 155–175.
search. Cyberpsychol Behav Soc Netw 2011; certainty, hypochondriacal concerns, obses- 23 Guo Y, Kuroki T, Yamashiro S, Koizumi S:
14:613–618. sive-compulsive symptoms, and worry. J Illness behaviour and patient satisfaction as
5 Muse K, McManus F, Leung C, Meghreblian Nerv Ment Dis 2012;200:208–213. correlates of self-referral in Japan. Fam Pract
B, Williams JM: Cyberchondriasis: fact or fic- 15 Starcevic V: Relationship between hypochon- 2002;19:326–332.
tion? A preliminary examination of the rela- driasis and obsessive-compulsive personality 24 von Scheele C, Nordgren L, Kempi V, Hetta J,
tionship between health anxiety and search- disorder: close relatives separated by nosolog- Hallborg A: A study of so-called hypochon-
ing for health information on the Internet. J ical schemes? Am J Psychother 1990;44:340– driasis. Psychother Psychosom 2010; 54:
Anxiety Disord 2012;26:189–196. 347. 50–56.
6 Starcevic V, Berle D: Cyberchondria: towards 16 Sakai R, Nestoriuc Y, Nolido NV, Barsky AJ: 25 Fergus TA: The Cyberchondria Severity Scale
a better understanding of excessive health-re- The prevalence of personality disorders in hy- (CSS): an examination of structure and rela-
lated Internet use. Expert Rev Neurother pochondriasis. J Clin Psychiatry 2010; 71: 41– tions with health anxiety in a community
2013;13:205–213. 47. sample. J Anxiety Disord 2014;28:504–510.
7 McElroy E, Shevlin M: The development and 17 Kellner R: Psychotherapeutic strategies in the 26 Norr AM, Allan NP, Boffa JW, Raines AM,
initial validation of the Cyberchondria Sever- treatment of psychophysiologic disorders. Schmidt NB: Validation of the Cyberchondria
ity Scale (CSS). J Anxiety Disord 2014; 28: Psychother Psychosom 1979;32:91–100. Severity Scale (CSS): replication and exten-
259–265. 18 Fava GA, Grandi S, Rafanelli C, Fabbri S, Caz- sion with bifactor modeling. J Anxiety Disord
8 Harding KJ, Skritskaya N, Doherty E, Fallon zaro M: Explanatory therapy in hypochondri- 2015;31:58–64.
BA: Advances in understanding illness anxi- asis. J Clin Psychiatry 2000;61:317–322. 27 Barke A, Bleichhardt G, Rief W, Doering BK:
ety. Curr Psychiatry Rep 2008;10:311–317. 19 McManus F, Leung C, Muse K, Williams The Cyberchondria Severity Scale (CSS): Ger-
9 Singh K, Fox JRE, Brown RJ: Health anxiety JMG: Understanding “cyberchondria:” an in- man validation and development of a short
and Internet use: a thematic analysis. Cyber- terpretative phenomenological analysis of the form. Int J Behav Med 2016;23:595–605.
psychol J Psychosoc Res Cyberspace 2016;10: purpose, methods and impact of seeking
article 4. health information online for those with
health anxiety. Cognitive Behaviour Thera-
pist 2014;7:e21.

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DOI: 10.1159/000465525