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. 2019 Jul 31;477(12):2665–2673. doi: 10.1097/CORR.0000000000000888

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

Julia Blackburn 1,2,3,4, Stefan F Fischerauer 1,2,3,4, Mojtaba Talaei-Khoei 1,2,3,4, Neal C Chen 1,2,3,4, Luke S Oh 1,2,3,4, Ana-Maria Vranceanu 1,2,3,4,✉
PMCID: PMC6907317  PMID: 31764332

Abstract

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.

Introduction

Searching for medical information on the internet has become common practice. However, because medical information can be complex and difficult to read [25], internet searches may only increase ambiguity. For people with a high intolerance of uncertainty, defined as those more likely to overestimate the likelihood of a negative outcome even for events with a low probability of occurring [5], this search for medical information may be particularly dangerous. For example, a patient experiencing “muscle twitching” may enter the information in an internet search engine, which will then list numerous conditions associated with that symptom. If the patient has a high intolerance of uncertainty, they will select from the list the most dangerous conditions, perhaps Parkinson’s disease or amyotrophic lateral sclerosis, thereby increasing anxiety and potentially continuing a process of compulsive internet searches and subsequent heightened emotional distress, which is termed cyberchondria. In contrast, people with a lower intolerance of uncertainty may be able to reassure themselves that they likely do not have Parkinson’s disease or amyotrophic lateral sclerosis, stop reading after one search, and wait to see if the twitch disappears.

Cyberchondria and intolerance of uncertainty have been shown to be associated with health anxiety [3, 7-10, 19, 21, 22, 34], which is an excessive worry about health and misinterpretation of normal body sensations or minor symptoms as severe illness. Health anxiety is associated with increased pain perception and functional impairment [28, 35, 36]. Intolerance of uncertainty, cyberchondria, and health anxiety are likely interrelated constructs that mutually reinforce each other over time. These constructs are not dichotomous, but rather exist on a continuum. In patients with orthopaedic illness, these constructs increase the risk of pain and disability as well as the risk of unnecessary medical procedures and increased health care costs. Therefore, it is important for surgeons to be aware of these associations and assess and educate patients to improve treatment outcomes.

Although the number of internet searches for medical information likely increases every day, very little research to date has examined cyberchondria and how it relates to health. The studies available [7, 9, 31, 32, 34] include only medically healthy participants from the community, rather than patients with symptoms. No studies of which we are aware have been conducted with orthopaedic patients. We were interested in understanding whether cyberchondria is a mediator (explanatory factor) of the association between intolerance of uncertainty and health anxiety in orthopaedic patients.

Mediation analysis is commonly used in social psychology to improve understanding of the relationship between psychological variables and identify potential targets for interventions [17]. Although it is more appropriate to use the language of association (for example, whether cyberchondria is associated with health anxiety) in observational studies, here, we opted to use the language of causation as is the convention in mediation analyses.

Mediation is a statistical test of a theoretical relationship among three or more variables (Fig. 1). A mediator can explain fully (full mediation) or partially (partial mediation) why two variables are interrelated. Mediation testing follows established rules [2, 17] and can be tested with a series of regression analyses. When mediation is conducted with cross-sectional data, one cannot fully assume causality. We know that patients with greater health anxiety will perform more searches of the internet for medical information; thus, patients with health anxiety will de facto have worse cyberchondria. However, for our study, we statistically imposed directionality because we were interested in all patients, not just those with health anxiety. People who have a greater intolerance of uncertainty may be more likely to search the internet for medical information and have greater anxiety, but the opposite relationship is also likely, because people with greater anxiety levels may also be more likely to search the internet for answers. Therefore, we examined the effect of cyberchondria on health anxiety rather than the reverse. The analysis can tell us whether some of the effect goes in the direction of interest. However, it is likely that the effect also goes from health anxiety to intolerance of uncertainty through cyberchondria.

Fig. 1.

Fig. 1

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(A) This diagram represents the mediation analysis. (B) This figure shows intolerance of uncertainty as the predictor, health anxiety as the outcome, and cyberchondria as the mediator. This figure also shows the effect of intolerance of uncertainty on cyberchondria (Path a), the effect of cyberchondria on health anxiety (Path b), the indirect effect (Path a × b), and the direct effect (Path c: the effect of intolerance of uncertainty on health anxiety that did not go through cyberchondria).

We therefore asked, 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?

Patients and Methods

Study Design and Setting

Participants in this cross-sectional study were recruited from two outpatient orthopaedic care clinics at one hospital, one hand and upper-extremity clinic and one sports medicine clinic, between June and August 2016. A research assistant approached potential participants while they waited for their appointment, explained the study’s procedures in detail, and obtained informed consent from those who agreed to participate. An information leaflet explained cyberchondria and the study’s intention to examine factors associated with cyberchondria. Patients were not incentivized to participate in the study, but were advised that completing the questionnaires would take them approximately 8 minutes.

Inclusion criteria were age at least 18 years, fluency in English, ability to provide informed consent, and history of searching the internet for any medical information about the current condition. Exclusion criteria were self-reported current pregnancy and any major, untreated psychopathology that would interfere with participation in the study, such as schizophrenia, untreated bipolar disorder, psychotic symptoms, or active substance abuse. Eligible participants completed demographic and self-reported measures on an encrypted device using REDCap® (Research Electronic Data Capture), an internet-based application designed to support secure data captures for research studies [15]. All study procedures were approved by our institutional review board and were performed in accordance with the latest version of the Declaration of Helsinki.

We approached 155 patients; 10 patients declined to participate and 41 were not eligible as per the exclusion criteria. Thirty-six of these 155 patients had not searched the internet for medical information, one had psychopathology from Parkinsonism, and four were unable to complete the questionnaires because of language fluency problems.

The recruited sample included 104 patients who had a mean age of 49 ± 15 years, and 59% were male. Patients had heterogeneous musculoskeletal conditions that represented the orthopaedic practices from which the patients were recruited (Table 1).

Table 1.

Descriptive and main study variables (n = 104)

graphic file with name abjs-477-2665-g002.jpg

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Measures

Cyberchondria

The Cyberchondria Severity Scale [20] was used to measure cyberchondria. The scale has 33 items (for example, "If I notice an unexplained bodily sensation I will search for it on the internet") answered on a five-point scale ranging from 1 ("Never") to 5 ("Always") [20]. Responses were summed up to a total score, with higher scores indicating greater levels of cyberchondria. The mistrust subscale was not included in calculating the total score because several authors consider this subscale a construct distinct from cyberchondria and strongly recommend its removal [8, 23].

Intolerance of Uncertainty

The Intolerance of Uncertainty Scale-short version [6] is a self-reported questionnaire assessing the tendency of an individual to consider it unacceptable that a negative event may occur, however small the probability of its occurrence [6]. Items such as “It frustrates me not having all the information I need” are answered on a five-point Likert-type scale ranging from 1 (“not at all characteristic of me”) to 5 (“entirely characteristic of me”), with higher scores denoting increased levels of uncertainty.

Health Anxiety

The Short Health Anxiety Inventory assesses worry about health, awareness of bodily sensations or changes, and feared consequences of having an illness [1]. Items are answered on a four-point Likert scale ranging from 0 to 3, with response choices varying based on the question (for example, “I .... think I have a serious illness”) [29]. Higher mean scores translate to higher health anxiety levels.

Pain Intensity

The numerical rating scale was used to measure the self-reported level of pain. Patients were asked to rate the level of pain in the prior week and choose a single number from an 11-point Likert-type scale ranging from 0 (“no pain”) to 10 (“worst pain ever”).

These three measures involve continuous data. Cyberchondria, intolerance of uncertainty, and health anxiety are not dichotomous, with a patient described as having these conditions or not. They are constructs and all people can display varying amounts of the condition in question.

Statistical Analysis

We used means and standard deviations to describe continuous data. We performed a series of bivariate zero-order statistical analyses using Pearson’s product-moment correlations, independent-sample t-tests, and one-way independent ANOVAs with Bonferroni corrections, as appropriate. Any variable with a significant (p < 0.05) bivariate association with the proposed mediator (cyberchondria), outcome variable (health anxiety), or both was considered a confounding factor and included in the “controlled” mediation analysis.

All study variables were interrelated except pain intensity, which did not correlate with cyberchondria (p = 0.718) or intolerance of uncertainty (p = 0.575) (Table 2). Greater health anxiety was associated with lower education (r = -0.19; p = 0.052) and multiple pain conditions (mean ± SD = 0.97 ± 0.07 versus 0.72 ± 0.04; p = 0.003). No demographic factors showed any association with cyberchondria. Therefore, we chose pain intensity, multiple pain conditions, and education as confounding variables.

Table 2.

Mediation effects of cyberchondria on the association between intolerance of uncertainty and health anxiety

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Mediation Analysis

We first performed three simple regression analyses to see whether an increase in intolerance of uncertainty will be associated with an increase in health anxiety (Path c: direct effect), whether an increase in intolerance of uncertainty will be associated with an increase in cyberchondria (Path a: indirect effect), and whether an increase in cyberchondria will be associated with an increase in health anxiety (Path b: indirect effect). The total effect is a combination of the indirect and direct effects. If all three regression analyses had significant results, an additional regression analysis was conducted to test whether the predictor (intolerance of uncertainty) is associated with the outcome (health anxiety) after controlling for the mediator (cyberchondria). Mediation occurs when the regression coefficient in this last test is lower than that in the regression analysis without the mediator (partial mediation: some of the effect of intolerance of uncertainty on health anxiety goes through cyberchondria) or is 0 (full mediation: all of the effect of intolerance of uncertainty on health anxiety goes through cyberchondria). For a partial mediator, the mediation effect size describes the proportion of the effect of intolerance of uncertainty on health anxiety that goes through cyberchondria. Mediation analyses were performed via Hayes’s PROCESS macro tool, version 2.16 (http://www.processmacro.org) for SPSS (IBM SPSS Statistics for Windows, Version 22.0; IBM Corp., Armonk, NY, USA), through a series of regression analyses. We statistically imposed intolerance of uncertainty as the predictor, health anxiety as the outcome, and cyberchondria as the mediator (Fig. 1A). We calculated the effect of intolerance of uncertainty on cyberchondria (Path a) and the effect of cyberchondria on health anxiety (Path b). We calculated the direct effect of intolerance of uncertainty on health anxiety that did not go through cyberchondria (Path c). We also calculated the indirect effect (Path a × b: the effect of intolerance of uncertainty on health anxiety through cyberchondria) and the total effect ([a × b] + c: the indirect plus direct effects of intolerance of uncertainty on health anxiety) (Fig. 1B).

To calculate the significance of an indirect effect, we used a Preacher and Hayes bootstrapping method [26, 27] and Sobel’s first-order product-of-coefficients test [18, 30]. The PROCESS tool then calculated the mediation effect size (the proportion of the indirect effect to the total effect).

Sample Size Determination

Fritz and Mackinnon [14] stipulated that a sample size of 71 is required to detect a medium effect size of 0.13 with 80% power when using a bias-corrected bootstrapped approach for inferring a mediation effect. An effect size refers to the strength of a relationship among variables. A medium effect size means that the relationship between variables will be moderate rather than weak (small effect size) or strong (large effect size). A larger sample size of approximately 50% more (104 patients) was enrolled to account for potential measurement errors found in psychosocial studies [16].

Results

After controlling for potential confounding variables including pain intensity, multiple pain conditions, and education level, our most definitive model calculated that cyberchondria accounted for 33% of observed health anxiety in patients with orthopaedic conditions (95% CI, 6.98 to 114.72). In the mediation analysis, b was the correlation coefficient with a standard error (SE) and p value (Table 3). We arrive at this finding through the following logic: cyberchondria was associated with health anxiety (Path b: b = 0.037; SE = 0.011; p = 0.012), and intolerance of uncertainty was associated with cyberchondria (Path a: b = 0.732; SE = 0.212; p = 0.001). The indirect effect of intolerance of uncertainty on health anxiety through cyberchondria was significant (b = 0.027; boot SE, 0.015; 95% CI, 0.007-0.065). Because the direct effect of intolerance of uncertainty on health anxiety was also significant (Path c: b = 0.054; p = 0.030), we concluded that cyberchondria partially mediates the effect of intolerance of uncertainty on health anxiety. The mediation effect size was 33%; thus, 33% of the total effect of intolerance of uncertainty on health anxiety is mediated by and through cyberchondria. The mediation was confirmed with Sobel’s test, a way of testing the significance of the mediation effect (z = 2.341; p = 0.019).

Table 3.

Mediation effects of cyberchondria on the association between intolerance of uncertainty and health anxiety

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Discussion

Previous studies have shown that cyberchondria [3, 7] and intolerance of uncertainty [10] are associated with health anxiety. Furthermore, adults with a greater intolerance of uncertainty are vulnerable to cyberchondria [10, 22]. However, all of these studies involved community volunteers rather than patients who reported having searched the internet for information about their current medical condition. We investigated whether greater cyberchondria might be associated with a greater intolerance of uncertainty and greater health anxiety (that is, mediation) among patients with orthopaedic illnesses who searched the internet for medical information about their condition. We confirmed that some of the effects of intolerance of uncertainty on health anxiety are associated with an increase in cyberchondria (that is, cyberchondria was a partial mediator of the effect of intolerance of uncertainty on health anxiety). Given the association between these constructs and pain, disability, and the risk of unnecessary medical procedures, it is important for surgeons to educate both themselves and their patients about these relationships. Patients with a high intolerance of uncertainty may also benefit from referral for skills training to learn to tolerate uncertainty about their symptoms or recovery trajectory [4].

The main limitation of this study is that as a cross-sectional study, we cannot conclude causation, which would require a longitudinal study design. Although we used the language of causation in this paper and discussed cyberchondria as a mediator of health anxiety as though the effect was unidirectional, cross-sectional study designs have limitations with respect to assessing causality in this context, and these effects are unquestionably bidirectional. However, mediation is frequently examined in cross-sectional studies [13, 33] in which hypotheses are driven by theoretical information, similar to this study. We acknowledge it is likely that there is a bidirectional relationship among intolerance of uncertainty, cyberchondria, and health anxiety. However, prior research depicted intolerance of uncertainty as the mechanism through which anxiety develops [10], and we wanted to test this directionality in our study. As such, we imposed statistical directionality to test our hypotheses by delineating which variables are predictors and which variables are outcomes when entering them into the regression analyses. In this way, we modeled the slope of the outcomes based on changes in the value of the predictor. In these analyses, we examined how cyberchondria affects health anxiety and learned that some of the effect goes in the direction of interest. A further limitation of our study is whether the included patients are generalizable to all orthopaedic patients. Our patients were recruited from two clinics that treat diverse musculoskeletal conditions, but they were predominantly white (95%) and had many years of education.

We confirmed that the indirect effect of intolerance of uncertainty on health anxiety was mediated by cyberchondria. This finding builds on previous work reporting that cyberchondria is closely linked to health anxiety [3, 7-9, 19, 21, 22] and that health anxiety can be fueled by both cyberchondria [34] and intolerance of uncertainty [10, 12]. Individuals with an intolerance of uncertainty are also known to be more likely to have cyberchondria [10, 22]. Furthermore, cyberchondria is associated with other anxiety-related disorders including obsessive compulsive disorder [8, 11, 24, 32] or psychological variables such as anxiety sensitivity and intolerance of uncertainty [7, 22]. However, none of these studies involved patients with orthopaedic problems. A study of patients consulting orthopaedic surgeons found that intolerance of uncertainty is important in the relationship among pain, pain anxiety, and physical function [13]. A further study of patients with upper-extremity musculoskeletal illnesses found that greater satisfaction with life reduces the effect of pain intensity on how much pain interferes with daily activities [33]. However, these studies did not consider the role of cyberchondria.

This study has important clinical implications. First, given the increased prevalence of internet searches and the lack of regulation of the quality of the medical information available online, it is important for orthopaedic surgeons to educate their patients about this issue, as well as provide them with information about the often unclear timeline of recovery after an orthopaedic condition develops. Second, it is important to assess intolerance of uncertainty with either questionnaires such as the ones used in this study or clinically as part of an orthopaedic examination. For example, a surgeon might say, “With many orthopaedic conditions, it is difficult to determine exactly when the pain will go away; it may be a number of weeks or more than a year. Some people have a hard time dealing with this. What about you?” This would allow for a conversation about intolerance of uncertainty, internet searches for medical information, and reassurance, as well as their potential negative effects on recovery. Similarly, it is also important to assess cyberchondria and health anxiety, either through self-report or as part of the general visit, allowing for patient education. In the interests of time in a busy clinic, assessing a patient’s tolerance of uncertainty may also give surgeons an objective measure to substantiate their intuition that a patient may struggle with their recovery. Finally, the surgeon can also consider introducing available resources to support the patient’s recovery, including skills-based cognitive behavioral therapy, to improve tolerance of uncertainty and improve recovery.

Acknowledgments

Julia Blackburn completed this work during a Fulbright Scholarship to do research with Dr. Chen at the Hand and Arm Center, Massachusetts General Hospital and Dr. Vranceanu at the Integrated Brain Health Clinical and Research Program. She thanks the Royal College of Surgeons of England and the US-UK Fulbright Commission for the opportunity.

Footnotes

Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

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