Self-diagnosis over the internet with the assistance of sites like WebMD is common, though the adverse implications for obsessional behavior associated with its use is a cause for concern. Many who use symptom checker sites engage with such behavior, which is worsened by individual concern and illness anxiety. Recognizing parallels in metacognition, the intervention of mental health professionals could lessen the frequency of self-diagnosis and the obsessional tendencies that often motivate their undertaking.
BACKGROUND
Symptom checker platforms are not populated by experts who can guide users toward useful conclusions. Instead, the general appearance of the website and the symptoms reported by the users without qualifying criteria are a kind of usher toward certain conditions. Whether or not an individual without hypochondriacal tendencies may develop these from using such a website is still yet to be fully deciphered; however, certain trends bring to light recurrent issues which suggest that symptom checkers’ lack of regulation could be deleterious to users.
In "How WebMD Convinces Us We're Dying," a Washington Post article, author Sarah Kliff distinguishes a somewhat disturbing trend in the platform's general usage. Kliff identifies that “those that went through the general symptoms first were more likely to self-diagnose themselves with cancer” (para 2). This much demonstrates the sometimes extreme diagnoses that are common among users of the WebMD platform.
From another angle, platforms like WebMD fail to provide users with rigorous diagnostic criteria by their design. The average user of a symptom checker website is not qualified to determine some of the more basic considerations which would be more evident to a physician, particularly one with whom a patient has maintained a rapport. Anxiety is separating an individual from useful conclusions about their health, however, may be palpable in more ways than one.
An article featured on Psychology Today digs deeper into what is known as cyberchondria. Cyberchondria is excessive health information seeking, sometimes between one and three hours a day, or more than three or four visits to a symptom checker website like WebMD (Whitbourne). The basic premise outlined here is that cyberchondria can contribute to a worse overall impression of personal wellness due to the hypochondriacal anxieties, which often accompany repeated platform usage.
Anxiety sensitivity is, in this way, a critical conception for those hoping to understand the limitations and impositions of cyberchondria better. In a collection of reflections on the topic, one author citing a relevant resource suggests that avoidance behaviors are common among those with anxiety sensitivity (Taylor 8). This is important insofar as avoidant social behaviors may also increase the likelihood that an anxious individual will opt not to visit a doctor in person; instead preferring to rely on Internet-based information from symptom checkers and unverifiable end-users.
Considering also that anxiety sensitivity is a somewhat new classification that is not thoroughly detailed in psychiatric resource materials and prognoses are even less favorable. Instances of anxiety sensitivity may well indicate later, worse conditions related to intensified feelings of panic, fear, or worry. That individuals with cyberchondria engage with such forms of cognition signals overlap between anxiety sensitivity and the behaviors which result from health information seeking.
The way in which people use symptom checker websites increases the likelihood of anxiety in the general population. Meanwhile, those who may have symptoms and demonstrate behaviors which are consistent with anxiety disorders are not likely to report these on a symptom checker as these are not their foremost concerns or reasons for venturing to such websites. Indeed, it is argued that the feelings that accompany these websites are less noticeable over time, particularly for those with symptoms consistent with cyberchondria.
Such websites precondition a worsening state of metacognition, which reinforces health problems. As another author for Psychology Today points out, metacognition is the active command over cognitive activity (Ethridge para 1). Ethridge notes that retaining and deploying such skills are two different processes. Lacking guidance on the WebMD platform, for example, users are forced to rely on an absent repertoire: without professional medical training, would-be patients opt for worst-case scenarios, thereby rendering anxious feelings.
Anxious feelings also overlap with experiences of depression. Stress and fear are often complementary to anxious and depressive states and conditions. Not paradoxically, such a takeaway is lost on those cyberchondriacs whom may benefit most from its elucidation by way of health information-seeking behaviors. Thus as anxious and depressive states worsen, obsessive behaviors are often even more frequent and intense.
Literature review
Obsessive or over-indulgent behaviors and feelings of anxiety related to one’s health constitute a condition of hypochondria. A not uncommon finding for some anxious patients by way of the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), hypochondria more specifically defines a class of diagnoses including somatic symptom disorder and illness anxiety disorder (American Psychiatric Association 310, 322). As hypochondriacal behavior can be self-defeating for some, the first of these is worth reviewing with more depth.
Somatic symptom disorder is excessive worry coupled with heightened feelings of anxiety, therein producing more violent ideations concerning personal health. Cyclical in nature, somatic symptom disorder typically only has one root cause, pain, which is subjectively intensified by concern (APA 311). The critical distinction, the authors of the DSM-V suggest, is that those with the disorder “tend to have very high levels of worry about illness” (311). In the contemporary age, this is worsened by the advent of some technologies that indulge those concerns without sufficient information or adequate qualification.
One critical distinction that is used to understand the present landscape better is that of cyberchondria, which has attracted some attention in recent years. Identified by Poel, Cyberchondria is an innate connection relating “health information seeking and anxiety” (32). Researchers in this study determined that those who had demonstrated a higher intensity and frequency of health anxiety symptoms were also more likely to engage in health information seeking. Thus there is a reciprocal relationship here, as with somatic symptom disorder, that should be more closely examined.
A few years prior, the topic of cyberchondria drew the attention of other researchers, who suggested that anxiety symptoms were worsened by the behaviors associated with health information seeking (Muse). Others, meanwhile, have contended that the somewhat more common and loosely defined condition, anxiety sensitivity, can be recognized as a premier risk factor for cyberchondria (Norr). Combined with this information, that aforementioned reciprocal relationship parallels another diagnosis: somatic symptom disorder.
Thus for hypochondriacs with diagnosed conditions, it would appear that cyberchondria, first prefigured by an innate concern about health, is augmented in personal reflection to a detrimental degree by specific actions. Exacerbated worry is connected to other anxiety disorders as well. For others who are more susceptible to anxiety overall, there is a burgeoning issue present in the appearance of symptoms coupled with anxiety sensitivity. Described by the authors of the DSM-V as “the disposition to believe that symptoms of anxiety are harmful,” (APA 211) anxiety sensitivity is closely related to diagnostic precursors of panic attacks and generalized anxiety disorder (GAD). Here is where a re-evaluation of symptom checkers becomes a critical interjection.
Cyberchondria is known to worsen the presence of anxiety as well as problematize health communication between a patient and a professional. Other researchers have recently noted that, in a pool of 32 studies, between 23% and 75% of an adult population in any given area within the U.S. were likely to use symptom checkers like WebMD (Mueller). Users often displayed subpar browsing habits and typically interacted with online content regarding severe conditions.
Those above represent two significant factors, which negatively affect the prospects of an individual with anxiety sensitivity, rather than exact symptoms related to hypochondria. If anxious tendencies about online symptom checkers proliferate without supervision a medical professional or researcher in as much as 75% of a population, it is reasonable to assert that these worsen in those undiagnosed over time. Add to this the fact that negative and irregular; sometimes drastic thoughts frequently accompany diagnoses related to anxiety and the conditions of those who do not practice rigorous research habits are thrown back into a familiar cycle: those of hypochondria and illness anxiety.
The metacognitive beliefs which underlie diagnoses of somatic symptom disorder and illness anxiety disorder are not dissimilar. All of these, in a sense, point to the under-investigated case of anxiety sensitivity as a sign of more severe and limiting conditions later in life. Many wait until conditions deteriorate. One does not seek professional assistance, for example, when anxiety sensitivity alone is present. Fergus and Spada contend, meanwhile, that cyberchondria itself is demonstrable in more desperate metacognitive beliefs — and, importantly, not anxiety sensitivity — exhibited in their two studies comprised of 597 participants in total.
Obsessive behaviors are informed and structured by such anxiety-inducing metacognitive beliefs. According to the authors of the DSM-V, obsessions are defined by “recurrent and persistent thoughts, urges, or images” (APA 237) that often experience unsuccessfully attempt to neutralize. This process is revealing in that the subject’s metacognition serves as a means of policing the discord fueled by anxious ideation. Determining how such recurrent episodes and visuals are propelling those feelings, however, is a self-directed process.
A final point of note in this review concerns the relationship between anxiety and depression. Panic attacks, anxious thoughts, and circular thinking are all hallmarks of depression, leading many experts to view such experiences as intensely related to one another. The fact remains that, since health information seeking behaviors promote frequency and intensity of anxiety in those with anxiety sensitivity, depression symptoms are likely to be augmented in those both diagnosed and otherwise as well. The result of such illness anxiety indulgent behavior is irrelevant: answers elicited from online symptom checkers strengthen metacognition associated with depression.
DISCUSSION
Anxiety has a foundational role in the constitution of an individual’s cognition. What might later be recognized as paranoiac, obsessional, or even depressive may be traceable back to a predisposition toward anxious ideation, or anxiety sensitivity. This is a crucial distinction that should inform methods in future research. Depression and anxiety are both worsened by the increased frequency of obsessional behaviors. Obsessional behaviors, cyclically defined as those that have anxious merit, contribute to a more negative pathological development of indulgent and self-harmful behavior hallmarked by lacking coping mechanisms for stress. Both anxiety and depression are, in a sense, controlled by metacognition.
Metacognition or the way in which subjects deploy mechanisms over lived thought, is not positively aided by the present formulation and operation of online symptom checkers. Where individuals learn social cues to navigate unfamiliar terrain, sites like WebMD offer no guidance as a means of legal protection. Were the platform to open itself up in this way, liability would be attached. Thus it can reasonably be asserted that WebMD profits from the paradigm.
Metacognitive beliefs may have a self-limiting, self-fulfilling element to them, according to Fergus and Spada. Researchers here overstate, though, when they assert that anxiety sensitivity may not be as closely linked to cyberchondria as the metacognitive beliefs like “the uncontrollability of thoughts” (Fergus and Spada 1322). Indeed, such a distinction is one so subtle that it fails to test under scrutiny. More likely is that anxiety sensitivity, which is so closely — by the language of the DSM-V — related to what the authors identify as separate metacognition that it may prefigure the occurrence of the latter.
The oversimplification committed by Fergus and Spada is recognized as emblematic of a more pervasive issue. Due to the somewhat innate undetectability of anxiety sensitivity, many with such a proclivity may allow related anxiety disorders to go unchecked until they take on a more severe form like GAD. As concerns subjective well-being in the long term, nuance is critical to deciphering the impact of anxiety on hypochondriacal behaviors.
The significant issue here concerns how patients may go about determining what is useful information. Without a clear inventory of factors impacting their browsing habits or even their self-reporting, for example, those undiagnosed with anxiety sensitivity who use sites like WebMD rely on their own worst perceptions. It is in this way that hypochondriacal symptoms, reaffirmed and heightened by anxiety-inducing health information seeking behavior on symptom checker websites, are not accounted for by those engaging in unhealthy browsing habits.
Limiting the occurrence of harmful symptoms related to diagnosable conditions should be a priority for platforms like WebMD. Of course, hypochondriacal symptoms are not necessarily common in the general population. Anxiety and its correlative, fear, are routinely recognized by all individuals in the course of one’s life. The authors of the DSM-V note that somatic symptoms are not present in roughly one in four hypochondriacs (APA 310). Thus not all instances of heightened anxiety result in such deleterious outcomes for WebMD users.
A shortage of useful information concerning how to interpret the information provided by symptom checker websites complicates use and may contribute to even more harmful conditions than those that the user sought to remedy. Katie Bessiere disputes that lacking health data and insufficient means of deciphering related information online is worsening depression rates. Considering that depression is a common thread among many other diagnosable conditions in the DSM-V, the multifaceted problem of illness anxiety is only further muddled.
Identifying anxiety early on is one essential measure that users could take on their own before using a symptom checker website to ensure that they are not aggravating their circumstance. Illness anxiety and anxiety sensitivity are distinguishably different occurrences that positively influence perceptions of fear related to one’s obsessional health information seeking behaviors. Going a step further to this end, one may note that WebMD and related platforms maintain the ability to warn users about the potential impact of conditions like GAD, chronic depression, or those related to hypochondria.
Bolstering personal understanding of how metacognition can be improved and wielded can only occur when platforms are transparent. Useful suggestions for the handling of anxiety and effects related to withdrawal from anxiolytics (known to rebound some of the most intense experiences related to one’s initial diagnosis) include physical symptom management, cognitive behavioral therapy (CBT) and others (Taylor 330). Taking such considerations in mind, future researchers may be able to offer a more succinct and widely available personal evaluative measure inventory of anxious effects (as are commonly associated with these measures), to determine whether anxiety sensitivity is present in a symptom checker user.
Obsessional tendencies that worsen feelings of anxiety and are presently part and parcel to the typical symptom checker experience contribute to, among other things, cyberchondria. Since, as Bessiere noted, depression rates similarly climb with such revelations, it is critical that symptom checker websites be more thoroughly investigated to discern how administrators can improve their functionality. The frequency of cyberchondria can be limited if the platform elements contributing to end-user fear or anxiety can be eliminated or curtailed.
Conclusion
By way of indulgent anxious tendencies common among those who use symptom checker services, internet self-diagnosis contributes to obsessional behaviors. Without professional assistance or even a technical evaluation tool, users are more inclined to feed into anxious precepts. Changing the metacognition associated with fear, anxiety, and depression through professional assistance, however, could simultaneously decrease symptom checker usage and bolster subjective well being.
WORKS CITED
American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders, 5th ed., American Psychiatric Publishing, 2013. DSM-V.
Bessière, Katie, et al. "Effects of internet use on health and depression: a longitudinal study." Journal of Medical Internet Research 12.1 (2010).
Ethridge, K. Metacognition and Motivation. 1 Nov. 2017, https://www.psychologytoday.com/us/blog/cognition-cafe/201711/metacognition-and- motivation.
Fergus, Thomas A., and Marcantonio M. Spada. "Cyberchondria: Examining relations with problematic Internet use and metacognitive beliefs." Clinical psychology & psychotherapy 24.6 (2017): 1322-1330.
Kliff, S. How WebMD Convinces Us We’re Dying. 19 Apr. 2012, https://www.washingtonpost.com/blogs/ezra-klein/post/how-WebMD-convinces-us-were-dying/2012/04/19/gIQA7v02ST_blog.html?utm_term=.3a0f07d466c2.
Mueller, Julia, et al. "Web Use for Symptom Appraisal of Physical Health Conditions: A Systematic Review." Journal of medical Internet research 19.6 (2017).
Muse, Kate, et al. "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 (2012): 189-196.
Norr, Aaron M., et al. "Anxiety sensitivity and intolerance of uncertainty as potential risk factors for cyberchondria." Journal of Affective Disorders 174 (2015): 64-69.
Taylor, Steven, ed. Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety. Routledge, 2014.
te Poel, Fam, et al. "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 (2016): 32-40.
Whitbourne, S. 5 Ways To Tell If You Have Cyberchondria. Psychology Today, https://www.psychologytoday.com/us/blog/fulfillment-any-age/201609/5-ways-tell-if- you-have-cyberchondria. Accessed 2 May 2018.