Journal of Anxiety Disorders 69 (2020) 102150

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Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

The impact of internet-delivered cognitive behavioural therapy for health T

anxiety on cyberchondria
Jill M. Newbya,b,*, Eoin McElroyc
a
School of Psychology, UNSW Sydney, 1302 Mathews Building, Randwick, NSW, 2052, Australia
b
Clinical Research Unit for Anxiety and Depression (CRUfAD), School of Psychiatry, UNSW Sydney at St Vincent’s Hospital, 390 Victoria Street Darlinghurst, NSW,
Sydney, 2010, Australia
c
Department of Neuroscience, Psychology and Behaviour, University of Leicester, University Road, Leicester, LE1 7RH, UK

A R T I C LE I N FO A B S T R A C T

Keywords: Cyberchondria refers to an emotional-behavioural pattern whereby excessive online searches lead to increased
Cyberchondria anxiety about one’s own health status. It has been shown to be associated with health anxiety, however it is
Health anxiety unknown whether existing cognitive behavioural therapy (CBT) interventions targeting health anxiety also
Illness anxiety disorder improve cyberchondria. This study aimed to determine whether internet-delivered cognitive behavioural
Online health information searching
therapy (iCBT) for severe health anxiety led to improvements in self-reported cyberchondria and whether im-
Somatic symptom disorder
provements 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 im-
provements 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.

1. Introduction reassurance-seeking from loved ones and health professionals about

Experiencing some anxiety about one’s health can be normal and
adaptive, but when health anxiety becomes persistent, excessive and
preoccupying, it can have a negative impact on the individual, their
loved ones and health professionals (Tyrer, Eilenberg, Fink, Hedman, &
Tyrer, 2016), and society (Bobevski, Clarke, & Meadows, 2016; Tyrer,
2018). Health anxiety is thought to be dimensional in nature, ranging
from normal, transient health worries to severe, and disabling health
anxiety. In the DSM-5 it is categorised as Illness Anxiety Disorder (IAD)
or Somatic Symptom Disorder (SSD) depending on the severity of the
individual’s somatic symptoms (American Psychiatric Association,
2013). Severe and functionally impairing health anxiety affects be-
tween 3–5% of the population (Creed & Barsky, 2004; Sunderland,
Newby, & Andrews, 2012).
People with health anxiety are afraid that they either have, or will
develop serious, often life-threatening illnesses. As a result of these
fears, they often engage in a range of behaviours such as excessive
their health concerns, which may temporarily allay their fears, but
maintain preoccupation with illness over the long term (Warwick &
Salkovskis, 1990). With free, private, and easily accessible health in-
formation available online, it is not surprising that people with health
anxiety frequently report searching the internet to seek reassurance
about their symptoms and health concerns (Muse, McManus, Leung,
Meghreblian, & Williams, 2012).
Exposure to information during online searches, especially
alarming, inaccurate and misleading information about life-threatening
illnesses (White & Horvitz, 2009) can exacerbate existing worries about
illnesses, and lead to new anxieties, causing an escalating pattern of
distress and further excessive and repeated online searches for health
information in a pattern labelled ‘cyberchondria’ (Starcevic and Berle,
2013). This phenomenon may be heightened by technical features of
online search engines. The algorithms that determine search results are
driven largely by the popularity of the available information, so that
frequently accessed web pages are given priority in search results. Thus,

⁎
Corresponding author at: School of Psychology, 1302 Mathews Building, UNSW Australia, Kensington, NSW, 2052, Australia.
E-mail address: j.newby@unsw.edu.au (J.M. Newby).

https://doi.org/10.1016/j.janxdis.2019.102150
Received 24 May 2019; Received in revised form 10 September 2019; Accepted 9 October 2019
Available online 31 October 2019
0887-6185/ © 2019 Elsevier Ltd. All rights reserved.
J.M. Newby and E. McElroy
searches of relatively benign symptoms may be biased to produce in-
formation about alarming, rare, life-threatening conditions. For in-
stance, White and Horvitz (White & Horvitz, 2009) found that the most
common result from a search of the term ‘muscle twitch’ was amyo-
trophic lateral sclerosis, despite the fact that it has an annual incidence
rate of 1 in every 55,000 persons.
The way that cyberchondria has been defined and conceptualised
has varied widely across studies. For the purposes of this study, we
conceptualise cyberchondria as having both a behavioural and emo-
tional component. The behavioural aspect of cyberchondria involves
excessive, and repeated online searches for health information that may
function similar to reassurance-seeking behaviour, where the individual
seeks reassurance online as opposed to in-person. The individual may
search online initially in an attempt to reduce distress, or to alleviate
their fears of illness or uncertainty about unexplained physical sensa-
tions. Some searches may temporarily alleviate the individual’s anxiety,
but serve to maintain anxiety long-term through maintaining the in-
dividual’s preoccupation with health concerns and difficulty tolerating
uncertainty about unexplained sensations. Individuals may search on-
line, but not feel reassured by the searches and instead experience
heightened distress and anxiety. That is, the searching causes escalating
distress, and prompts further online searching, which further escalates
distress and future searches. The emotional component of cyberchon-
dria is the distress, or anxiety caused by the searching, or the inability
to control the searching behaviour.
There is an ongoing debate as to whether cyberchondria is a core
feature of health anxiety (Starcevic & Berle, 2013), or whether it con-
stitutes a distinct concept in its own right (Fergus & Russell, 2016;
Mathes, Norr, Allan, Albanese, & Schmidt, 2018). Cross-sectional stu-
dies have shown a strong association between cyberchondria and health
anxiety (2014, Fergus, 2013; Mathes et al., 2018; Norr, Albanese,
Oglesby, Allan, & Schmidt, 2015; Norr, Allan, Boffa, Raines, & Schmidt,
2015; Norr, Oglesby et al., 2015). A recent meta-analysis of 20 studies,
including 7373 participants showing a positive correlation between
health anxiety and cyberchondria (r = 0.62) (McMullan, Berle, Arnaez,
& Starcevic, 2019). However, psychometric analyses have supported
meaningful a distinction between cyberchondria and health anxiety
(Fergus & Russell, 2016). Furthermore, the direction of causality be-
tween online health searches and health anxiety may also vary between
individuals, meaning the behavioural cycle of cyberchondria cannot be
considered, in all cases, purely the result of pre-existing health anxiety.
Although people with elevated health anxiety report a greater fre-
quency of online health information searches, along with greater re-
sultant anxiety (Doherty-Torstrick, Walton, & Fallon, 2016; Muse et al.,
2012; Singh & Brown, 2016), it is has been demonstrated that in-
dividuals without an existing tendency towards health worries can ex-
perience elevated levels of distress/anxiety as a result of searching
behaviour (te Poel, Baumgartner, Hartmann, & Tanis, 2016). Such
searches may be prompted by curiosity or the sudden emergence of an
unexplained symptom (Starcevic, 2017). Together, these findings sug-
gest that cyberchondria can be conceptualised as a unique pattern of
behaviours and emotions that undoubtedly plays an important role in
health anxiety, and therefore needs to be targeted in treatment.
To our knowledge, there is no research on the treatment of cy-
berchondria, either alone or in the context of health anxiety (McMullan
et al., 2019; Starcevic & Berle, 2013). The current study sought to ad-
dress this gap by examining, for the first time, whether clinician-guided
internet-delivered CBT for health anxiety improves cyberchondria, in a
sample of participants who met criteria for DSM-5 diagnoses of IAD
and/or SSD. Clinician-guided iCBT has previously been shown to be
effective at improving health anxiety (Hedman et al., 2011, 2014;
Hedman, Axelsson, Andersson, Lekander, & Ljótsson, 2016; Newby
et al., 2016), mirroring the success of face-to-face CBT protocols (see
Cooper, Gregory, Walker, Lambe, & Salkovskis, 2017; Thomson & Page,
2007 for reviews on CBT).
In a previous paper, the development of a new iCBT program for
2
Journal of Anxiety Disorders 69 (2020) 102150
health anxiety was outlined (the ‘Health Anxiety Program’) (Newby
et al., 2016). The iCBT program included psychoeducation about health
anxiety, and taught CBT skills to target the cognitive and behavioural
processes that are proposed to maintain health anxiety (Warwick &
Salkovskis, 1990), including cognitive therapy components to change
maladaptive interpretations of bodily symptoms and beliefs about
health and illness, and behavioural strategies to reduce excessive
checking, reassurance-seeking and avoidance of situations that trigger
illness fears (e.g., hospitals, conversations about illness). In addition to
these strategies, the program educated participants about the role of
online health information searching (‘Googling behaviours’) in ex-
acerbating health anxiety and preoccupation with illness. It also taught
participants to become more aware of, self-monitor, and reduce ex-
cessive online health information searching through behavioural ex-
periments, activity scheduling, and other strategies to delay and pre-
vent unhelpful online searching about symptoms and illness.
We expected the iCBT program to be helpful at reducing the beha-
vioural and emotional components of cyberchondria via several ave-
nues. For example, this intervention aimed to increase awareness of the
frequency of online searching and the unhelpful personal costs of online
searching, and taught practical strategies to prevent, delay and stop
online searching behaviour once it started. We expected these strategies
to help health anxious participants to reduce the frequency and dura-
tion of online health information searching, and in turn also prevent
escalations in distress that can occur through excessive and repeated
searching. In addition, the iCBT program taught participants how to
relate to symptoms and health information in a different way. For ex-
ample, they developed new ways of thinking about unexplained bodily
sensations and health information, as opposed to relying on cata-
strophic ‘worst case scenario’ thinking patterns and assumptions. Once
an individual can develop their own less threatening interpretations of
bodily sensations, and improve their ability to tolerate uncertainty
about these sensations, we expected them to rely less on internet
searches to alleviate anxiety. In addition, by learning how to regulate
negative emotions including anxiety, coupled with the ability to think
more clearly, rationally, and in less negatively biased interpretation
style, we expected that they should be able to both prevent anxiety from
escalating, and alleviate the anxiety more quickly after online searches.
Through facilitating these changes, we expected health anxiety to re-
duce. We therefore expected reductions in cyberchondria would be
associated with improvements in health anxiety symptoms.
In a randomised controlled trial (Newby et al., 2018), we showed
that iCBT for health anxiety had large and superior effects in reducing
health anxiety compared to an active control group who received online
anxiety psychoeducation, support and monitoring from a clinician. As
part of that RCT, we also aimed to examine the impact of the iCBT
program on cyberchondria, and administered the self-report Cyberch-
ondria Severity Scale (CSS) before and after a 12-week treatment period
to achieve this aim. The CSS contains five subscales that assess the
multidimensional construct of cyberchondria. These include the Com-
pulsion (the degree to which online health information interrupts daily
activities), Distress (emotional distress associated with online health
information searching), Excessiveness (seeking out repeated, and fre-
quent sources of information), Reassurance (anxiety leading from on-
line searches to seeking opinions from other experts of health profes-
sionals) and Mistrust of Health Professionals subscales (whether online
information is trusted more than health professionals) subscales. Our
primary aim in the current study was to explore whether iCBT for
health anxiety improves cyberchondria (and specific subscale ratings)
relative to the control group. Our second aim was to explore whether
improvements in cyberchondria were associated with improvements in
health anxiety using mediation analyses. We hypothesised that iCBT
would outperform the control group in improving cyberchondria, and
that improvements would be associated with changes in symptoms of
health anxiety.
J.M. Newby and E. McElroy
2. Methods
2.1. Participants
Participants who met criteria for a diagnosis of DSM-5 IAD or SSD
(participants with SSD must endorse criterion B2 for SSD ‘persistently
high level of anxiety about health or symptoms’) who were on a stable
dose of psychological and/or pharmacotherapy for the two months
prior to intake assessment were eligible to participate. Applicants were
not eligible to participate if they had a self-reported diagnosis of psy-
chosis or bipolar disorder, currently used antipsychotic or regular
benzodiazepine medications, or had severe depression (defined as
scoring > 24 on the Patient Health Questionnaire 9-item [PHQ-9]).
These exclusion criteria were set due to safety reasons, to maintain
consistency with our previous trial protocols, and to minimise the
possibility of concurrent pharmacotherapies interfering with the effi-
cacy of the CBT techniques (e.g., exposure components).
2.2. Trial design
Eligible participants were randomised to either iCBT or the control
group (n = 45 for iCBT, and n = 41 for control group), and completed
assessments at pre-, mid-, post-treatment and 3-month follow-up (iCBT
group only, as the control group was crossed over to iCBT after post-
treatment assessment). The CSS was only administered at pre and post-
treatment. The SHAI was administered at each lesson to track changes
in symptoms. The previous manuscript reporting the main RCT findings
(Newby et al., 2018) reported the results for the iCBT and control
groups on self-reported health anxiety severity, and a range of other
outcomes, including generalised anxiety, depression, distress, body
hypervigilance, and maladaptive cognitions. The CSS results have not
been reported previously.
2.3. Ethics approval and informed consent
All participants provided electronic informed consent to participate
in the study. The study involving the clinical sample was approved by St
Vincent’s Hospital Human Research Ethics Committee (HREC/14/SVH/
294) and registered with the Australian and New Zealand Clinical Trials
Registry (ACTRN12615000887572).
2.4. Interventions
2.4.1. Internet CBT
The Health Anxiety Course is a 6-lesson illustrated comic-style online
program delivered via the Virtual Clinic website (www.virtualclinic.
org.au)1 over 12 weeks. After a participant completed a lesson, they
were required to wait a minimum 5 days until the next lesson was re-
leased. Participants were encouraged to complete one lesson per week
to fortnight, however, they were able to complete the program at their
own pace, with a maximum of 12 weeks to complete the 6 lessons. The
program delivered psychoeducation, and CBT skills including detecting
and challenging negative thinking patterns about bodily symptoms and
health, exposure to feared situations and sensations, behavioural stra-
tegies to reduce checking, reassurance-seeking and googling about
symptoms, and relapse prevention.
Importantly, strategies to reduce unhelpful and excessive googling
of symptoms were included in Lesson 2. In this lesson, excessive goo-
gling was conceptualised as a form of unhelpful checking behaviour.
Participants read psychoeducation about the unhelpful role of googling,
and how it can exacerbate health anxiety, maintain preoccupation with
illness fears, and trigger new fears. First, the lesson explained how
googling may have lead to immediate, temporary relief from anxiety,
1
For a free demonstration of the course, contact the first author.
3
Journal of Anxiety Disorders 69 (2020) 102150
but that this relief is often short-lived. It also taught how googling can
lead to unintended negative effects, such as exacerbating existing fears,
maintaining focus and preoccupation with anxieties, lead to new fears
of illness, and lead to incorrect self-diagnoses. They were also taught
about the variable quality of online health information, and how more
highly ranked websites in search engines are ranked by popularity not
necessarily their accuracy, and that ‘alarming and threatening, worst
case scenario’ information, stories of suffering and mistaken diagnoses
are often higher in the search results, rather than factual or benign
information. Finally, the module tips to become an ‘expert searcher’.
Tips included keeping track of, and learning to identify triggers for
internet searching, and replacing triggers with alternative activities
using Activity Planning; checking only credible websites, such as health
experts, and government websites; avoiding searching for vague
symptoms; and stopping searching when it exacerbates anxiety. Finally,
they were encouraged to conduct a behavioural experiment to compare
anxiety levels, and health preoccupation when they avoid searching
versus when they search the internet.
It also included a ‘checking prevention plan’ to develop strategies to
prevent the participant from googling excessively including using be-
havioural activation and other distracting strategies, as well as beha-
vioural experiments to test cognitions about googling about symptoms.
Participants were encouraged to read the online module, and complete
key skills practice exercises between the lessons. Participants in this
group received email and/or phone contact with the clinician (JN, a
PhD-level Clinical Psychologist) after lessons 1 and 2 to encourage
progress, and after subsequent lessons clinician contact was made upon
patient request or if the patient reported significant deterioration (in-
creased distress) or suicidal ideation. If participants stopped logging in,
they were sent up to two automated emails to remind them to complete
their next lesson. In addition, the clinician attempted to contact the
participant via email or phone if the participant did not respond to the
automated emails, or login after they were prompted. The clinician
spent on average 43.11 min per participant on email and telephone
contact in the iCBT group (SD = 25.75, range = 13–116 minutes).
2.4.2. Control group
Fact sheets (2–4 pages) were delivered online each fortnight on
topics related to anxiety (e.g., The fight-or-flight response, Causes of
anxiety, How to Manage Stress). Participants were offered clinician
contact via email or phone. Phone contact was made if the participant
reported significant deterioration in distress or depression symptoms, or
suicidal ideation. The clinician spent an average of 23.20 min
(SD = 13.74, range = 8–61) minutes per participant in the control
group.
2.5. Diagnostic interview
Participants were administered an abbreviated telephone-adminis-
tered Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) (Brown
& Barlow, 2014) prior to being included in the study to confirm whe-
ther they met criteria for an IAD, or SSD diagnosis or comorbid IAD and
SSD (Brown & Barlow, 2014).
2.6. Clinical outcomes
The primary outcome was health anxiety according to the 18-item
Short Health Anxiety Inventory (SHAI) (Salkovskis, Rimes, Warwick, &
Clark, 2002). Cyberchondria was assessed using the 33-item Cyberch-
ondria Severity Scale (McElroy & Shevlin, 2014).
2.6.1. The Short Health Anxiety Inventory (SHAI) (Salkovskis et al., 2002)
The SHAI is a validated 18-item self-report measure of the severity
of health anxiety symptoms over the past week. The measure has good
psychometric properties including good internal consistency, test-retest
reliability and construct validity, and is sensitive to treatment
J.M. Newby and E. McElroy
(Abramowitz, Deacon, & Valentiner, 2007; Alberts, Hadjistavropoulos,
Jones, & Sharpe, 2013). Participants are asked to rate each item with
four response options to examine cognitive and behavioural features of
health anxiety. Items are rated on a four point scale, ranging from 0 to 3
(for example, the first item is: 0 = I do not worry about my health,
1 = I occasionally worry about my health, 2 = I spend much of my time
worrying about my health, and 3 = I spend most of my time worrying
about my health).
2.6.2. Cyberchondria Severity Scale (CSS) (McElroy & Shevlin, 2014)
The CSS is a validated 33 item self-report measure of cyberchondria.
Items (e.g., “If I notice an unexplained bodily sensation I will search for
it on the internet”) are rated on a 5-point scale, ranging from 1-5. The
CSS has a total score, as well as five subscales: Compulsion scale,
Distress subscale, Excessiveness subscale, Reassurance subscale, and a
Mistrust of Medical Professionals subscale. The scale has been validated
in undergraduate and community samples (Norr, Albanese et al., 2015;
Norr, Allan et al., 2015; Norr, Oglesby et al., 2015) and shown to have
high internal consistency, and good convergent and divergent validity,
as demonstrated by higher correlations with measures of health anxiety
(r = 0. 54 – 0.59; Fergus, 2014; Norr, Oglesby et al., 2015) compared
with other forms of anxiety, e.g. OCD (r = 0.34 – 0.45; Norr, Oglesby
et al., 2015) and generalised anxiety (r = 0.39; McElroy & Shevlin,
2014). Chronbach’s alpha’s in the current sample were 0.96 for the
Total scale, 0.96 for the Compulsion scale, 0.81 on the Mistrust scale,
0.85 for the Reassurance, 0.91 for the Excessiveness subscale, 0.95 for
the Distress subscale.
2.7. Statistical analyses
Treatment efficacy was evaluated using repeated measures analyses
of variance (ANOVAs). Because the CSS was only measured at pre- and
post-treatment in the two treatment groups, linear mixed models were
judged not to be appropriate, given they would not have added addi-
tional value. Within- and between-groups effect sizes (Hedges g) were
calculated and interpreted using standard guidelines: 0.2 = small ef-
fect, 0.5 = medium effect, 0.8 = large effect (Cohen 1988). Due to
recent evidence showing that the cyberchondria Mistrust subscale does
not load on the same factors as the other subscales of the CSS (Fergus,
2014), we chose to analyse the subscales separately, as well as the CSS
Total score results. The analyses of the health anxiety outcomes have
been reported previously in the original paper (Newby et al., 2018), and
have also been included in the current paper for clarity of interpreting
the results. The CSS results have not been reported previously. The CSS
results were not included in the previous report because it was only
administered at two time points, whereas the remaining measures were
administered at multiple time points.
2.7.1. Mediation analyses
Tests of the indirect effects (mediation) were conducted using
PROCESS (Hayes, 2013). Estimates of indirect effects were generated
using bootstrapping analysis (see Preacher & Hayes, 2004; Preacher,
Rucker, & Hayes, 2007). Bootstrapping is a nonparametric resampling
method that generates an estimate of the indirect effect, and does not
require assumptions about the shape of the sampling distribution that
underlie the Sobel test. In bootstrapping analysis, the most stringent
test of an indirect effect (mediation) is if the 95% bias corrected and
accelerated confidence intervals for the indirect effect do not include
the value of 0. When zero is outside of the 95% confidence interval
estimate, the indirect effect is declared statistically different from zero
at p < .05 (two-tailed), indicating that the effect of the independent
variable on the dependent variable is contingent upon the effect of the
proposed mediator (Preacher & Hayes, 2004). In the current study, we
estimated 5000 bias-corrected bootstrap 95% confidence intervals
using PROCESS for SPSS (Hayes, 2012).
We estimated several separate mediation models, with changes in
4
Journal of Anxiety Disorders 69 (2020) 102150
cyberchondria (either the total scale score, or the separate subscale
scores) as the mediator variable (M) using PROCESS (Hayes, 2013).
This enabled us to test the indirect effects of treatment (where 0 =
control, and 1= iCBT) on post-treatment health anxiety severity (SHAI
scores) via changes in cyberchondria. Baseline SHAI scores were en-
tered as a covariate in all analyses. A positive change score between pre
and post-treatment evidenced an improvement in ratings. All 95% bias-
corrected bootstrapped confidence intervals for the indirect effects are
presented in brackets.
3. Results
3.1. Participants
Forty-five iCBT participants, and 41 participants in the control
group completed baseline questionnaires; of these data were collected
from 37/45 participants at post-treatment in the iCBT group and 32/41
participants in the control group.
3.1.1. Demographic and sample characteristics
Participants were 30 years on average (SD = 12 years,
range = 18–65), the majority were female (87.2 %, n = 75), and half
were either married or living in a de facto relationship (n = 43, 50 %).
Most were either in part-time or full time paid work (n = 61, 70.9 %),
spoke English as their main language (94.2 %, n = 81), and were well
educated having completed year 12 or equivalent (n = 19, 22.1 %), or a
tertiary degree (n = 37, 43 %).
The mean score on the SHAI was 35.77 (SD = 7.21,
range = 16–49), and the average age of onset of health anxiety was 21
years (SD = 9, range: 8–55). For further details of the sample, see
Newby et al. (2018). In terms of DSM-5 diagnoses, there was an even
split of IAD (n = 39, 45.3 %) and SSD (n = 39, 45.3 %), and 8 had
comorbid IAD and SSD (17 %). On average, participants met criteria for
3.2 diagnoses (SD = 1.7). The most common comorbidity was gen-
eralised anxiety disorder (GAD) (n = 43, 50 %), then panic disorder
(39.5%), agoraphobia (n = 31, 36.0 %), and major depressive disorder
(MDD) (n = 31, 36 %). Fifteen participants were receiving concurrent
counselling (17.4 %) with 3 (3.5%) receiving current CBT that had
started at least 2 months prior to initial assessment, and 16 were on
antidepressant medications (18.6 %). There were no significant differ-
ences between the two groups on any baseline characteristics or
treatment expectancy.
3.1.2. Primary outcomes: impact of internet CBT on health anxiety, and
cyberchondria
The time by group interactions were statistically significant for the
SHAI, Total scores on the CSS as well as the Compulsion, Distress,
Reassurance, and Excessiveness subscales (all p’s < .001, except for the
Reassurance subscale where p < .05). The between-group differences
on the SHAI, and CSS Compulsion, Distress and Excessiveness subscales
were large ranging from 0.8 (Distress) to 1.15 (Compulsion). There
were only moderate between-group differences on the Reassurance
subscale favouring the iCBT group (g = 0.56). In contrast, the time by
group interactions for the Mistrust subscale was not statistically sig-
nificant (p > .05), and there were small non-significant differences fa-
vouring the control group (g=-0.1) on the Mistrust subscale. See
Table 1 for results.
3.1.3. Mediation analyses
Results of the mediation analysis indicated that the total effect of
treatment on post-treatment SHAI scores was significant (B=-11.44,
t=-6.13, SE = 1.86, p < .001). The indirect effect of treatment on
post-treatment health anxiety via reductions in cyberchondria (CSS
Total) scores between pre- and post-treatment was supported, as the
indirect effect was statistically different from zero (95%CI: -8.18 to
-2.60). In addition, the indirect effect of treatment on post-treatment
J.M. Newby and E. McElroy Journal of Anxiety Disorders 69 (2020) 102150

Table 1
Observed means and standard deviations of the online cognitive behavioural therapy program and control group on health anxiety and cyberchondria severity scale
subscales.
Measure Baseline Post Within Between-group post-treatment F (time by group)
Mean ES ES (Hedge’s g)
(95%CI) (95%CI)
Baseline to Post Post-treatment
M SD M SD

iCBT SHAI 35.11 7.18 19.81 7.87 2.15 (1.58–2.72) 1.36 (0.83-1.88) F(1,67) = 29.88, p < .001
Control SHAI 35.81 7.73 31.63 9.41 0.50 (0.00–1.00)
iCBT CSS Total 102.16 21.41 70.78 22.60 1.41 (0.90–1.92) 1.09 (0.58-1.59) F(1,67) = 22.64, p < .001
Control CSS Total 104.50 22.68 96.22 24.17 0.23 (–0.26–0.72)
iCBT CSS Compulsion 21.27 7.72 12.97 6.21 1.27 (0.77–1.77) 1.15 (0.64-1.66) F(1,67) = 16.73, p < .001
Control CSS Compulsion 22.56 7.45 20.94 7.51 0.16 (−0.33–0.66)
iCBT CSS Distress 28.68 6.60 19.05 8.31 1.30 (0.38–1.81) 0.80 (0.31-1.30) F(1,67) = 17.56, p < .001
Control CSS Distress 28.81 7.42 26.03 7.95 0.23 (−0.26–0.73)
iCBT CSS Reassurance 16.38 4.57 12.41 4.92 0.66 (0.19–1.13) 0.56 (0.08-1.05) F(1,67) = 6.68, p < .05
Control CSS Reassurance 16.47 5.46 15.38 5.51 0.13 (−0.3–0.62)
iCBT CSS Excessiveness 27.89 7.29 18.62 6.52 1.85 (1.31–2.40) 1.13 (0.62-1.63) F(1,67) = 25.07, p < .001
Control CSS Excessiveness 28.75 6.67 26.44 7.24 0.21 (−0.28–0.70)
iCBT CSS Mistrust 7.95 2.44 7.73 3.10 0.11 (−0.35–0.56) −0.10 (-0.58-0.36) F(1,67) = 0.12, p = 0.73
Control CSS Mistrust 7.91 2.41 7.44 2.26 0.15 (−0.34–0.64)
iCBT CSS Total (without mistrust subscale) 94.22 20.07 63.05 22.34 1.57 (1.05–2.09) 1.11 (0.60-1.61) F(1,67) = 25.41, p < .001
Control CSS Total (without mistrust subscale) 96.59 22.27 88.78 23.71 0.36 (−0.13–0.86)

Note. iCBT, n = 37, control: n = 32. CSS = Cyberchondria Severity Scale.

health anxiety via reductions in CSS Compulsion subscale scores (B:
-3.72; 95%CI: -7.13 to -1.65), Distress subscale scores (B: -3.35; 95%CI:
-5.92 to -1.60), Excessiveness subscale scores (B: -4.24; 95%CI: -7.44 to
-1.91), and Reassurance subscale scores (B: -2.29; 95%CI: -4.55 to
-0.61) were all significant. However, the indirect effects via reductions
in the Mistrust subscale scores was not significant (B: -.01; 95%CI: -.32
to 0.56). Together these results suggest that reductions in health an-
xiety were partly mediated by reductions in cyberchondria severity,
except for Mistrust scores.
4. Discussion
People who experience health anxiety often report excessive, and
distressing online searches for health information, in a pattern called
‘cyberchondria’. This study is the first to our knolwedge to examine the
impact of CBT for health anxiety in any modality (e.g., in-person, in-
ternet) on cyberchondria. In a clinical treatment-seeking sample of
health anxious participants with DSM-5 Illness Anxiety Disorder and/or
Somatic Symptom Disorder, we found that the clinician-guided iCBT
group experienced large improvements in cyberchondria from pre- to
post-treatment. The iCBT group also reported significantly lower cy-
berchondria severity at post-treatment relative to the control group
who received online anxiety psychoeducation, clinical support and
monitoring (Newby et al., 2018). These findings add to a growing body
of literature supporting the positive effects of iCBT on health anxiety
(Hedman et al., 2011, 2014; Hedman et al., 2016; Newby et al., 2016).
We found a different pattern of results across the five subscales of
the Cyberchondria Severity Scale (CSS) (McElroy & Shevlin, 2014),
with large improvements observed in the iCBT group on the Distress,
Excessiveness and Compulsion subscales, and moderate improvements
on the Reassurance subscale. It is possible that these findings were due
to positive response bias, or demand characteristics. However, these
results suggest that iCBT may help health anxious individuals to reduce
the excessive nature of online health information searches, the distress
caused, and reduce the impact of online searching on daily activities.
iCBT may also have a positive impact on the degree to which online
searches motivate further reassurance-seeking from experts or health
professionals (the Reassurance subscale), but this effect appears smaller
than the other dimensions of cyberchondria.
In contrast to these results, we failed to find any changes on the
Mistrust of Medical Professionals subscale, in either group. McElroy and
Shevlin (2014) originally developed this subscale based on the results of
exploratory factor analysis, which revealed a five factor model (see
Selvi, Turan, Sayin, Boysan, & Kandeger, 2018 for a replication of the
five factor model). However, more recently, other researchers have
questioned the utility of the Mistrust subscale (Fergus, 2014; Norr,
Allan et al., 2015), in part because items on this scale (e.g., ‘I trust my
GP/medical professional’s diagnosis over my online self-diagnosis’) are
reverse scored, unlike the other subscales, and in part because the
Mistrust subscale does not correlate as well with other cyberchondria
subscales, or health anxiety (Barke, Bleichhardt, Rief, & Doering, 2016;
Selvi et al., 2018). In addition, recent factor analytic studies found that
the mistrust factor may be a separate and distinct factor to the other
factors (Fergus, 2014; Norr, Allan et al., 2015), suggesting that the
mistrust factor may not be central to cyberchondria (Norr, Allan et al.,
2015). These findings again call into question the utility of the Mistrust
subscale, consistent with Fergus (2014) who suggested ‘the Mistrust
subscale should not be used when creating a CSS total score’ (p509,
Fergus, 2014). However, Fergus (2014) found that this subscale ex-
plained unique variance in health anxiety scores in a community
sample, beyond the other CSS subscales, suggesting it may be an im-
portant construct to assess, and may tap into a separate dysfunctional
belief that is associated with health anxiety. In addition, although the
scores were elevated on this scale (baseline mean of 7.9 on the Mistrust
subscale out of a total possible score of 15), it is possible that the scores
were not elevated enough to improve substantially from baseline to
post-treatment. Nonetheless, iCBT did not appear to change scores on
these items.
Due to the length of the CSS (33 items) we only administered it at
baseline and post-treatment, to minimise assessment burden on parti-
cipants. Therefore, the findings of the mediation analysis need to be
interpreted with caution because we cannot establish a causal re-
lationship between the proposed mediator (cyberchondria) and the
outcome (health anxiety) (Thoemmes, 2015). However, our pre-
liminary results suggest that improvements in health anxiety in the
iCBT group may be mediated by improvements in cyberchondria se-
verity ratings, on all subscales except for the Mistrust subscale. Further
research is required to test the causal relationship(s) between these two
constructs during and after treatment. For instance, the integration of
mediation analyses into experimental or quasi-experimental designs
(i.e. the collection of data pre-trial, post-trial and at a later follow-up)
would help determine whether reductions in cyberchondria lead to

5
J.M. Newby and E. McElroy
subsequent reductions in health anxiety, or vice versa (Jose, 2016).
Furthermore, the use of experience sampling methodologies (ESM) in
the context of clinical trials may shed light on momentary processes.
For instance, in future trials we could include regular measures of both
cyberchondria and health anxiety immediately prior to each lesson to
explore the time course of changes in these processes, and the causal
role of changes in cyberchondria on health anxiety. Such research may
help further our understanding of the degree to which cyberchondria
and health anxiety are intertwined. Although brief versions of the CSS
(12-item English version; McElroy et al., 2019) and a 15-item German
version (Barke et al., 2016) have been developed in order to minimise
participant burden, further refinement or new measurement ap-
proaches may be required in order to adequately capture cyberchondria
in an ESM design.
4.1. Clinical implications
Our findings have important implications for assessment, and
treatment of cyberchondria. First, they suggest that CBT for health
anxiety, which include components that directly target excessive online
health information searching, can successfully improve cyberchondria
severity, in treatment-seeking individuals with DSM-5 IAD and/or SSD
diagnoses. It is not yet clear whether multicomponent CBT for health
anxiety, or cyberchondria-specific interventions achieve better results.
We also do not know which components of our existing program are
most effective for reducing cyberchondria. We included component to
reduce and target excessive googling behaviour in the second module of
the program, which specifically educated participants about the po-
tential role of online health information searching (‘Googling’) in
worsening symptoms of health anxiety and attentional hypervigilance
toward bodily symptoms and threatening sensations. However, the
program also incorporated a range of other cognitive and behavioural
therapy techniques which may have had an indirect, positive impact on
online searching behaviour. For example, participants were taught to
develop alternative (neutral) explanations for their symptoms to reduce
catastrophic thinking, and strategies to reduce excessive body hy-
pervigilance and body checking. These strategies may have reduced
anxiety and fears of illness, in turn reducing the urge to search online
about symptoms and feared illnesses. Future research could incorporate
module-by-module assessment of cyberchondria and health anxiety, or
test the specific effects of specific treatment components using dis-
mantling designs, to determine which components are critical in re-
ducing cyberchondria.
4.2. Limitations
The results of this study need to be interpreted in the context of
some limitations. All of the data was collected via online self-report
measures, as there is currently no validated clinical interview to assess
cyberchondria. The findings need to be replicated using objective
measures of online searching behaviour. Second, the sample was mo-
tivated, treatment-seeking, and generally well educated; it is unknown
whether the findings generalise to other samples, including whether
iCBT would have as powerful effects for those who were not treatment
seeking, or those convinced by medical explanations for their symp-
toms. Third, another limitation of this study was that we did not ex-
plicitly ask participants whether they used the internet to search for
health information. Rather, we used the Cyberchondria Severity Scale
(CSS), which is the most widely used measure of cyberchondria
(McMullan et al., 2019) used to assess the severity of cyberchondria on
a dimensional scale. For each of the 33 items of the CSS, participants
choose a response from the following options: Never, Rarely, Some-
times, Often and Always. There were no participants who endorsed the
‘Never’ response option on all of the items, which suggests that these
participants did engage in online health information searching. None-
theless, future studies should ask explicitly about whether or not the
6
Journal of Anxiety Disorders 69 (2020) 102150
participant searches the internet for health information, to add further
context to the meaning of the CSS scores.
In addition, there are some other limitations of the CSS that are
important to highlight. Scores on this scale are moderately correlated
with health anxiety; therefore the positive changes we observed on this
scale in the iCBT group may have been reflective of general improve-
ments in health anxiety, rather than a unique or distinct process. This
measure confounds the presence of unexplained bodily sensations and
medical illnesses, with the behavioural (e.g., frequency of searching)
and emotional (e.g., distress associated with searching) components of
cyberchondria. It is not known whether the gains for cyberchondria are
maintained long-term, although the improvements in self-reported
health anxiety severity were maintained in the iCBT group at 3-month
follow-up (Newby et al., 2018). Replication by independent research
teams with a larger sample, weekly self-report and objective measures
of online searching behaviour, and a longer-term follow-up assessment
is needed.
4.3. Conclusions
This is the first study to show that clinician-guided internet CBT
reduces cyberchondria in a sample of patients with DSM-5 diagnoses of
Illness Anxiety Disorder and Somatic Symptom Disorder. Our findings
provide support for the use of CBT to reduce cyberchondria in health
anxious samples.
Declaration of Competing Interest
None.
Acknowledgements
Funding: This work was supported by the Australian National
Health and Medical Research Council (NHMRC) Early Career
Fellowship (grant number: 1037787) and Medical Research Future
Fund Career Development Fellowship (grant number 1145382)
awarded to Dr Jill Newby, and a St Vincent’s Clinic Foundation grant
awarded to Dr Jill Newby.
References
Abramowitz, J., Deacon, B., & Valentiner, D. (2007). The short health anxiety inventory:
Psychometric properties and construct validity in a non-clinical sample. Cognitive
Therapy and Research, 31(6), 871–883. https://doi.org/10.1007/s10608-006-9058-1.
Alberts, N. M., Hadjistavropoulos, H. D., Jones, S. L., & Sharpe, D. (2013). The short
health anxiety inventory: A systematic review and meta-analysis. Journal of Anxiety
Disorders, 27(1), 68–78. https://doi.org/10.1016/j.janxdis.2012.10.009.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental dis-
orders (fifth edition). Arlington, VA: American Psychiatric Association.
Barke, A., Bleichhardt, G., Rief, W., & Doering, B. K. (2016). The cyberchondria severity
scale (CSS): German validation and development of a short form. International Journal
of Behavioral Medicine, 23(5), 595–605. https://doi.org/10.1007/s12529-016-
9549-8.
Bobevski, I., Clarke, D. M., & Meadows, G. (2016). Health anxiety and its relationship to
disability and service use: Findings from a large epidemiological survey.
Psychosomatic Medicine, 78(1), 13–25.
Brown, T. A., & Barlow, D. (2014). Anxiety and related disorders interview schedule for DSM-
5 (ADIS-5). New York: Oxford University Press.
Cooper, K., Gregory, J. D., Walker, I., Lambe, S., & Salkovskis, P. M. (2017). Cognitive
behaviour therapy for health anxiety: A systematic review and meta-analysis.
Behavioural and Cognitive Psychotherapy, 45(2), 110–123. https://doi.org/10.1017/
s1352465816000527.
Creed, F., & Barsky, A. (2004). A systematic review of the epidemiology of somatisation
disorder and hypochondriasis. Journal of Psychosomatic Research, 56(4), 391–408.
https://doi.org/10.1016/s0022-3999(03)00622-6.
Doherty-Torstrick, E. R., Walton, K. E., & Fallon, B. A. (2016). Cyberchondria: Parsing
health anxiety from online behavior. Psychosomatics, 57(4), 390–400. https://doi.
org/10.1016/j.psym.2016.02.002.
Fergus, T. A. (2013). Cyberchrondria and intolerance of uncertainty: Examining when
individuals experience health anxiety in response to internet searches for medical
information. Cyberpsychology, Behavior and Social Networking, 16(10), 735–739.
https://doi.org/10.1089/cyber.2012.0671.
Fergus, T. A. (2014). The Cyberchondria Severity Scale (CSS): An examination of
J.M. Newby and E. McElroy
structure and relations with health anxiety in a community sample. Journal of Anxiety
Disorders, 28(6), 504–510. https://doi.org/10.1016/j.janxdis.2014.05.006.
Fergus, T. A., & Russell, L. H. (2016). Does cyberchondria overlap with health anxiety and
obsessive–compulsive symptoms? An examination of latent structure and scale in-
terrelations. Journal of Anxiety Disorders, 38, 88–94. https://doi.org/10.1016/j.
janxdis.2016.01.009.
Hayes, A. (2013). Introduction to mediation, moderation, and conditional process analysis: A
regression-based approach. New York: The Guilford Press.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable media-
tion, moderation, and conditional process modeling. KS: University of Kansas.
Hedman, E., Andersson, G., Andersson, E., Ljotsson, B., Ruck, C., Asmundson, G. J., ...
Lindefors, N. (2011). Internet-based cognitive-behavioural therapy for severe health
anxiety: Randomised controlled trial. The British Journal of Psychiatry, 198(3),
230–236.
Hedman, E., Axelsson, E., Andersson, E., Lekander, M., & Ljótsson, B. (2016). Exposure-
based cognitive–Behavioural therapy via the internet and as bibliotherapy for so-
matic symptom disorder and illness anxiety disorder: Randomised controlled trial.
The British Journal of Psychiatry. https://doi.org/10.1192/bjp.bp.116.181396.
Hedman, E., Axelsson, E., Gorling, A., Ritzman, C., Ronnheden, M., El Alaoui, S., &
Ljotsson, B. (2014). Internet-delivered exposure-based cognitive-behavioural therapy
and behaviouralstress management forsevere health anxiety: Randomised controlled
trial. The British Journal of Psychiatry, 205(4), 307–314. https://doi.org/10.1192/bjp.
bp.113.140913.
Jose, P. E. (2016). The merits of using longitudinal mediation. Educational Psychologist,
51(3–4), 331–341. https://doi.org/10.1080/00461520.2016.1207175.
Mathes, B. M., Norr, A. M., Allan, N. P., Albanese, B. J., & Schmidt, N. B. (2018).
Cyberchondria: Overlap with health anxiety and unique relations with impairment,
quality of life, and service utilization. Psychiatry Research, 261, 204–211. https://doi.
org/10.1016/j.psychres.2018.01.002.
McElroy, E., Kearney, M., Touhey, J., Evans, J., Cooke, Y., & Shevlin, M. (2019). The CSS-
12: Development and validation of a short-form version of the cyberchondria severity
scale. Cyberpsychology, Behavior and Social Networking, 22(5), 330–335. https://doi.
org/10.1089/cyber.2018.0624.
McElroy, E., & Shevlin, M. (2014). The development and initial validation of the cy-
berchondria severity scale (CSS). Journal of Anxiety Disorders, 28(2), 259–265.
https://doi.org/10.1016/j.janxdis.2013.12.007.
McMullan, R. D., Berle, D., Arnaez, S., & Starcevic, V. (2019). The relationships between
health anxiety, online health information seeking, and cyberchondria: Systematic
review and meta-analysis. Journal of Affective Disorders, 245, 270–278. https://doi.
org/10.1016/j.jad.2018.11.037.
Muse, K., McManus, F., Leung, C., Meghreblian, B., & Williams, J. (2012).
Cyberchondriasis: Fact or fiction? A preliminary examination of the relationship
between health anxiety and searching for health information on the Internet. Journal
of Anxiety Disorders, 26(1), 189–196.
Newby, J. M., Mahoney, A., Mason, E., Smith, J., Uppal, S., & Andrews, G. (2016). Pilot
trial of a therapist-supported internet-delivered cognitive behavioural therapy pro-
gram for health anxiety. Internet Interventions, 6, 71–79. https://doi.org/10.1016/j.
invent.2016.09.007.
Newby, J. M., Smith, J., Mahoney, A., Mason, E., Uppal, S., & Andrews, G. (2018).
Internet-based cognitive behavioural therapy versus psychoeducation control for
illness anxiety disorder and somatic symptom disorder: A randomised controlled trial.
Journal of Consulting and Clinical Psychology, 86(1), 89–98. https://doi.org/10.1037/
ccp000024.
Norr, A. M., Albanese, B. J., Oglesby, M. E., Allan, N. P., & Schmidt, N. B. (2015). Anxiety
Journal of Anxiety Disorders 69 (2020) 102150
sensitivity and intolerance of uncertainty as potential risk factors for cyberchondria.
Journal of Affective Disorders, 174, 64–69. https://doi.org/10.1016/j.jad.2014.11.
023.
Norr, A. M., Allan, N. P., Boffa, J. W., Raines, A. M., & Schmidt, N. B. (2015). Validation of
the Cyberchondria Severity Scale (CSS): Replication and extension with bifactor
modeling. Journal of Anxiety Disorders, 31, 58–64. https://doi.org/10.1016/j.janxdis.
2015.02.001.
Norr, A. M., Oglesby, M. E., Raines, A. M., Macatee, R. J., Allan, N. P., & Schmidt, N. B.
(2015). Relationships between cyberchondria and obsessive-compulsive symptom
dimensions. Psychiatry Research, 230(2), 441–446. https://doi.org/10.1016/j.
psychres.2015.09.034.
Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect
effects in simple mediation models. Behavior Research Methods, Instruments, &
Computers, 36, 717. https://doi.org/10.3758/BF03206553.
Preacher, J., Rucker, D., & Hayes, A. F. (2007). Addressing moderated mediation hy-
potheses: Theory, methods, and prescriptions. Multivariate Behavioral Research, 42,
185–227. https://doi.org/10.1080/00273170701341316.
Salkovskis, P., Rimes, K., Warwick, H., & Clark, D. (2002). The Health Anxiety Inventory:
Development and validation of scales for the measurement of health anxiety and
hypochondriasis. Psychological Medicine, 32(5), 843–853. https://doi.org/10.1017/
S0033291702005822.
Selvi, Y., Turan, S., Sayin, A., Boysan, M., & Kandeger, A. (2018). The cyberchondria se-
verity scale (CSS): Validity and reliability study of the Turkish version, Vol. 20.
Singh, K., & Brown, R. J. (2016). From headache to tumour: An examination of health
anxiety, health-related Internet use and’ query escalation’. Journal of Health
Psychology, 21(9), 2008–2020. https://doi.org/10.1177/1359105315569620.
Starcevic, V. (2017). Cyberchondria: Challenges of problematic online searches for
health-related information. Psychotherapy and Psychosomatics, 86(3), 129–133.
https://doi.org/10.1159/000465525.
Starcevic, V., & Berle, D. (2013). Cyberchrondria: towards a better understanding of
excessive health-realted Internet use. Expert Review of Neurotherapeutics, 13(2),
205–213. https://doi.org/10.1586/ERN.12.162.
Sunderland, M., Newby, J. M., & Andrews, G. (2012). Health anxiety in Australia:
Prevalence, comorbidity, disability and service use. The British Journal of Psychiatry.
https://doi.org/10.1192/bjp.bp.111.103960.
te Poel, F., Baumgartner, S. E., Hartmann, T., & Tanis, M. (2016). The curious case of
cyberchondria: A longitudinal study on the reciprocal relationship between health
anxiety and online health information seeking. Journal of Anxiety Disorders, 43,
32–40. https://doi.org/10.1016/j.janxdis.2016.07.009.
Thoemmes, F. (2015). Reversing arrows in mediation models does not distinguish plau-
sible models. Basic and Applied Social Psychology, 37(4), 226–234. https://doi.org/10.
1080/01973533.2015.1049351.
Thomson, A. B., & Page, L. A. (2007). Psychotherapies for hypochondriasis. The Cochrane
Database of Systematic Reviews(4), CD006520. https://doi.org/10.1002/14651858.
CD006520.pub2.
Tyrer, P. (2018). Recent advances in the understanding and treatment of health anxiety,
Vol. 20.
Tyrer, P., Eilenberg, T., Fink, P., Hedman, E., & Tyrer, H. (2016). Health anxiety: the
silent, disabling epidemic. BMJ, 353. https://doi.org/10.1136/bmj.i2250.
Warwick, H. M., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research and
Therapy, 28(2), 105–117. https://doi.org/10.1016/0005-7967(90)90023-c.
White, R. W., & Horvitz, E. (2009). Cyberchondria: Studies of the escalation of medical
concerns in Web search. ACM Transactions on Information and System Security, 27(4),
1–37. https://doi.org/10.1145/1629096.1629101.