INTRODUCTION
The COVID-19 pandemic has significantly impacted the utilization of cancer care [1], leading to concerns about the shortage of medical professionals and healthcare facilities for patients with cancer. To address this, COVID-19-specific guidelines have been developed to minimize the risk of infection while considering the potential risks and benefits of active treatment [2]. However, the shift in cancer care utilization has led to undesirable consequences, including diagnoses at more advanced stages and psychological distress [3]. Furthermore, fear of cancer progression may be directly influenced by anxiety related to the COVID-19 pandemic [4] or indirectly, due to changes in cancer treatment plans during the pandemic. Patients with cancer worried about being infected with the virus, believing their immune function was compromised [4]. They were reluctant to visit the hospital to protect themselves and expressed concerns while receiving healthcare services [5]. We previously reported that anxiety toward coronavirus in patients with cancer directly influenced their fear of disease progression, with this relationship mediated by cancer-related dysfunctional beliefs about sleep [4]. Based on the results, we can speculate that patients with cancer with higher level of anxiety toward coronavirus may fear cancer progression and take steps to prevent viral transmission from others.
People with hypochondriasis possess an excessive worry about having serious diseases, even after ascertainment of normal medical work-up. Individuals who fear being sick may experience anxiety, leading them to seek reassurance or avoid confronting the issue. However, this short-term relief may ultimately reinforce the original fear, causing the individual to become more preoccupied with the illness [6]. During the COVID-19 pandemic, the cognitive-behavioral model of hypochondriasis6 suggests that repetitive reassurance-seeking behavior about COVID-19 infection increased anxiety about contracting the virus among the general population, leading individuals to become obsessed with the possibility of viral infection [7]. Similarly, we observed the relationship between anxiety toward coronavirus, reassurance-seeking behavior, and preoccupation with the virus among medical students, who experienced fear of infection during their clerkships [8]. However, the cognitive-behavioral model of hypochondriasis has not been previously applied to the vicious cycle of COVID-19-related hypochondriasis among patients with cancer.
During the COVID-19 pandemic, other psychological factors may have contributed to the development of COVID-19-related hypochondriasis. Intolerance of uncertainty—the inability to tolerate the distress caused by the absence of important or sufficient information [9]—can exacerbate anxiety toward coronavirus during a pandemic. Among patients with cancer, intolerance of uncertainty is related to psychological distress [10,11]. During this pandemic, we observed that intolerance of uncertainty mediated the impact of anxiety toward coronavirus on social distancing phobia in the general population [12]. Additionally, it influenced adherence to physical distancing, mediated by anxiety toward coronavirus, among healthcare workers [13]. Furthermore, we reported that intolerance of uncertainty may be included in the vicious cycle of COVID-related hypochondriasis [14]. Among patients with cancer, intolerance of uncertainty was associated with higher levels of psychological distress [10], and both intolerance of uncertainty and fear of COVID-19 were associated with increased stress and anxiety [11].
Patients with cancer commonly suffer from sleep disturbances, regardless of their cancer stages. Moreover, cancer can cause various physical symptoms, such as nausea, vomiting, and widespread pain, which can lead to insomnia. Many patients with cancer have dysfunctional beliefs about sleep and worry about the negative effects of insomnia. First, they commonly believe that poor sleep quality could lead to cancer progression or metastasis. Second, patients with cancer often become preoccupied with their sleep timing, believing it is essential for maintaining a strong immune system. These dysfunctional beliefs about sleep may mediate the impact of anxiety toward coronavirus on fear of progression among patients with cancer [4].
The aim of this study was to investigate whether cognitive-behavioral models of illness anxiety disorder can be effectively applied to COVID-related hypochondriasis. Furthermore, we examined the role of intolerance of uncertainty and cancer-related dysfunctional beliefs about sleep in the cognitive-behavioral model of COVID-related hypochondriasis. We hypothesize that, among patients with cancer, there is a positive correlation between coronavirus reassurance-seeking behavior and preoccupation with the virus (Hypothesis I). Additionally, anxiety toward coronavirus is positively linked to preoccupation with the virus (Hypothesis II), intolerance of uncertainty is positively related to preoccupation with the virus (Hypothesis III), and cancer-related dysfunctional beliefs about sleep are positively related to preoccupation with the virus (Hypothesis IV). Furthermore, intolerance of uncertainty may partially mediate the relationship between reassurance-seeking behavior and preoccupation with the virus (Hypothesis V), while cancer-related dysfunctional beliefs about sleep may also partially mediate this relationship (Hypothesis VI).
METHODS
Participants and procedures
This anonymous online survey study was conducted from March to June 2022 at a tertiary medical center. A poster inviting participation was displayed at the Cancer Institute, and patients with cancer voluntarily took part in this survey. The survey included questions about participants’ demographics such as age, sex, marital status, cancer type, cancer stage, and current treatment modalities. It also addressed COVID-19-related questions, including “Have you been quarantined due to COVID-19 infection?,” “Have you been infected with COVID-19?,” and “Did you get vaccinated?” Past psychiatric symptoms were assessed by the question “Did you experience or receive treatment for depression, anxiety, or insomnia?,” while the current need for psychiatric help was evaluated with the question “Do you think you are currently depressed or anxious, or do you feel you need help to improve your mood?” The survey form was developed according to the Checklist for Reporting Results of Internet e-Surveys (CHERRIES) guidelines [15], and investigators tested the usability and technical functionality of the survey form prior to implementation. To understand how patients with cancer interact with the prototype form, we asked volunteer nurses, who work in the Asan Medical Center Cancer Institute to complete the survey. They tested how well the form opened when they clicked the link and whether the answers were properly applied when selected. Based on the feedback from the pre-testers, the survey flow and text errors were revised. This study protocol was approved by the Asan Medical Center Institutional Review Board (IRB No. 2022-0054) and informed consent was obtained from all participants accordingly. Participants received an e-gift coupon worth approximately $5 for their participation.
Measures
Obsession with COVID-19 Scale
The Obsession with COVID-19 Scale (OCS) is a self-report measure used to assess persistent distressing thoughts related to COVID-19 [16], consisting of four items that are rated on a scale of 0 (not at all) to 4 (nearly every day over the last 2 weeks). A higher total score indicates a greater preoccupation with COVID-19. The Korean version of the OCS was used in this study [17]. Since the OCS was not validated among patients with cancer, we analyzed its reliability and validity in our sample. Sampling was adequate (Kaiser-Meyer-Olkin [KMO]=0.811), and data was suitable for factor analysis (Bartlett’s test for sphericity, p<0.001). The Confirmatory Factor Analysis (CFA) revealed a good fit for the single factor model of the OCS (comparative fit index [CFI]=1.000, Tucker-Lewis index [TLI]=1.000, root-mean-square-error of approximation [RMSEA]=0.000, standardized root-mean square residual [SRMR]=0.022). Factor loadings of all items ranged from 0.69-0.87 (Supplementary Table 1). Cronbach’s alpha among this sample was 0.873.
Coronavirus Reassurance-seeking Behaviors Scale
The Coronavirus Reassurance-seeking Behaviors Scale (CRBS) is a self-rating scale which was developed to measure an individual’s reassurance-seeking behavior related to coronavirus [18]. It has five items which can be rated on a 5-point scale (0: not at all-4: nearly every day). A higher total score means a higher level of reassurance-seeking tendency related to coronavirus. We applied the Korean version of the scale in this study [19], which was validated among patients with cancer in Korea [20], and Cronbach’s alpha among this sample was 0.917.
Stress and Anxiety to Viral Epidemics-6 items
The Stress and Anxiety to Viral Epidemics-6 items (SAVE-6) is a self-rating scale which can measure an individual’s anxiety toward coronavirus [21] derived from the SAVE-9 scale [22]. It has six items which can be rated on a 5-point Likert scale (0: never-4: always). A higher total score means a higher level of anxiety toward coronavirus. The SAVE-6 was already validated among patients with cancer [23], and we applied the original Korean version of the scale in this study. Cronbach’s alpha among this sample was 0.884.
Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14 items
The Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14 items (C-DBAS-14) scale was a composite scale of the Dysfunctional Beliefs and Attitudes about Sleep-16 items (DBAS-16) [24] and Cancer-related Dysfunctional Beliefs about Sleep (C-DBS) scales [25]. The C-DBAS-14 scale can measure cancer-related dysfunctional beliefs about sleep in patients with cancer, as it includes items from the C-DBS [25], such as the questions, “My immune system will have serious problems if I don’t go to sleep at a certain time” and “If I don’t sleep well at night, my cancer may recur or metastasize.” The 14 items of the C-DBAS-14 are rated on a Likert-type scale from 0 (strongly disagree) to 10 (strongly agree), and the total score is calculated by summing scores of all items and dividing by 14. A higher total score reflects a higher level of dysfunctional beliefs about sleep. The Korean version of the C-DBAS-14 was validated [26], and Cronbach’s alpha was 0.951 among this sample.
Intolerance of Uncertainty-12 items scale
The Intolerance of Uncertainty-12 items (IUS-12) scale is a self-rating scale which can assess one’s level of tolerance of uncertainty [27]. It has 12 items which can be rated on a 5-point Likert scale (1: not at all characteristic of me-5: entirely characteristic of me). A higher total score means a higher level of intolerance of uncertainty. The Korean version of the IUS-12 was used in this study [28]. Cronbach’s alpha among this sample was 0.951.
Statistical analysis
A summary of the demographic characteristics and rating scale scores is shown in the form of mean and standard deviation (SD). The level of significance for the analyses was defined as two-tailed at values of p<0.05. First, we explored the reliability and validity of the OCS among patients with cancer, as described in the methods section. The normality assumption was assessed based on skewness, which ranged within ±2, and kurtosis, which ranged within ±7 [29]. Sampling adequacy and data suitability were explored using KMO measure and Bartlett’s test of sphericity. CFA was run to examine the structure validity of the OCS. A satisfactory model fit for the factor structure was defined by an SRMR value of 0.05, RMSEA value of 0.10, and CFI and TLI values of 0.90. Reliability of internal consistency was assessed using Cronbach’s alpha.
Second, we evaluated the feasibility of the cognitive-behavioral model of COVID-related hypochondriasis among patients with cancer. We measured Pearson’s correlation coefficients between age and rating scale scores. To investigate variables which predict cancer-related dysfunctional beliefs about sleep, a linear regression analysis was conducted with Enter method. Using the variables included in the linear regression analysis, the bootstrap method with 2,000 resamples was implemented to explore whether intolerance of uncertainty mediates the influence of reassurance-seeking behavior on cancer-related dysfunctional beliefs about sleep. We used SPSS version 21.0, AMOS version 27 for Windows (IBM Corp.), and JASP 0.16.4 (JASP team) to perform the statistical analysis.
RESULTS
A total of 154 patients with cancer responded to this survey, with a mean age of 48.2 years (SD=9.7). Among the participants, 127 (82.5%) were females, of whom 35 (22.7%) were single (Table 1). Most participants (n=151, 98.1%) were diagnosed as having a solid tumor, and two-thirds had breast cancer (n=102, 66.2%). Based on TNM staging system (n=141), 13 participants (9.2%) were classified as stage IV, and 17 participants (12.1%) reported that they did not know their exact cancer stage. Two-thirds of the participants were undergoing current cancer treatment (n=101, 65.6%), and 13 (8.4%) were within 3 months postoperatively.
Pearson’s correlation coefficients among clinical variables are shown in Table 2. Young age significantly correlated with CRBS score (r=-0.23, p<0.01). The OCS score significantly correlated with CRBS (r=0.84, p<0.01), SAVE-6 (r=0.65, p<0.01), IUS-12 (r=0.56, p<0.01), and C-DBAS-14 (r=0.41, p<0.01). The CRBS score significantly correlated with SAVE-6 (r=0.62, p<0.01), IUS-12 (r=0.49, p<0.01), and C-DBAS-14 (r=0.43, p<0.01). The SAVE-6 score significantly correlated with IUS-12 (r=0.62, p<0.01) and C-DBAS-14 (r=0.61, p<0.01). The IUS-12 score correlated with C-DBAS-14 (r=0.62, p<0.01).
Table 3 shows the results of linear regression analysis with the Enter method to explore the variables expecting preoccupation with coronavirus among patients with cancer. It revealed that the OCS was expected by CRBS (β=0.71, p<0.001), SAVE-6 (β=0.15, p=0.032), and IUS-12 (β=0.18, p=0.003) (adjusted R2=0.74, F=84.4, p<0.001). In Table 4 and Figure 1, the mediation analysis results are presented. It shows that dysfunctional beliefs did not directly influence preoccupation with coronavirus, but this relationship was completely mediated by anxiety toward coronavirus, coronavirus reassurance-seeking behavior, and intolerance of uncertainty.
DISCUSSION
In this study, we examined the reliability and validity of the OCS among patients with cancer. The OCS is a reliable and valid rating scale which can be applied to patients with cancer to measure their level of preoccupation with coronavirus. We further hypothesized that anxiety toward coronavirus, coronavirus reassurance-seeking behavior, intolerance of uncertainty, and cancer-related dysfunctional beliefs about sleep are positively correlated with preoccupation with coronavirus among patients with cancer. Our results established these hypotheses to be true. Additionally, we hypothesized that intolerance of uncertainty or cancer-related dysfunctional beliefs about sleep partially mediate the impact of coronavirus reassurance-seeking behavior on preoccupation with the virus among patients with cancer. In the linear regression analysis, C-DBAS-14 was not included as an expectation for OCS, and dysfunctional beliefs about sleep were not considered as mediators. Therefore, we rebuilt the model in which anxiety toward coronavirus, reassurance-seeking, and intolerance of uncertainty could be mediators between dysfunctional beliefs about sleep and preoccupation with coronavirus (Figure 1).
We measured the feasibility of the model using coronavirus-specific rating scales such as the SAVE-6, CRBS, or OCS, which were developed to assess psychological distress of the general population during the COVID-19 pandemic. Among these scales, the SAVE-6 and CRBS were already validated among patients with cancer in Korea [20,23]. The reliability and validity of the OCS, which had not been previously reported among patients with cancer, were explored using the sample in this study. The OCS showed good reliability of internal consistency and good convergent validity, compared to SAVE-6 or CRBS, which were already validated as coronavirus-specific rating scales among patients with cancer. In terms of item 4 of the OCS, “I dreamed about the coronavirus,” the skewness was 2.53, and kurtosis was 5.64. This survey was conducted from March to June 2022, two years after the COVID-19 outbreak initiated. Item 4 was a difficult item for patients with cancer to answer evenly. However, based on the CFA, we observed strong factor loadings for all items, and a good fit for the model as a single factor.
In this study, we observed that the cognitive-behavioral model of COVID-related hypochondriasis is feasible among patients with cancer. This model helps us understand the behaviors of patients with cancer during the COVID-19 pandemic. They may be more likely to seek repetitive reassurance during the COVID-19 pandemic due to their high anxiety levels. Continual reassurance can ultimately lead to increased anxiety and obsessiveness about the possibility of viral infection. For instance, patients with cancer may excessively wash their hands or repeatedly check their temperature, to the extent that it interferes with their daily life. However, anxiety toward coronavirus and reassurance-seeking may not be distressing to all patients with cancer. Some may feel that the COVID-19 pandemic provides them with a sense of control over their environment [30]. These patients may take precautions against the virus, such as wearing a mask and practicing social distancing, to the extent that it gives them a sense of safety and security. In this way, the COVID-19 pandemic may reduce anxiety levels in some patients with cancer [31].
Intolerance of uncertainty, a cognitive predisposition described as fear of the unknown [27], was one of the expecting variables for preoccupation with coronavirus in this study. It was reported that intolerance of uncertainty contributed to health anxiety. In addition, intolerance of uncertainty mediated the influence of loneliness on hypochondriasis [32] among older adults. During the COVID-19 pandemic, intolerance of uncertainty was reported to be related with health anxiety [33]. It influenced perceived burden [34], fear of progression [35], or psychological distress in patients with cancer, even during the COVID-19 pandemic [36]. Since their intolerance of uncertainty might be related with their anxiety toward the virus, we considered including this psychological factor in the model of COVID-related hypochondriasis.
We also considered that cancer-related dysfunctional beliefs about sleep might be influenced by psychological status related to viral infection. We previously reported that dysfunctional beliefs about sleep mediated the influence of anxiety toward coronavirus on fear of cancer progression [4]. The COVID-19 pandemic led to increased anxiety in patients with cancer, who are considered a high-risk group [37]. These patients are often aware of the weakened state of their immune systems that makes them vulnerable to viral infections. Patients with cancer, who have dysfunctional beliefs about sleep, might think that their sleep disturbances decrease their immune function [25], and as a result, they may also worry about the risk and the negative effects of viral infection [38]. At this point, we discussed the possibility that cancer-related dysfunctional beliefs about sleep could be addressed in the model of COVID-related hypochondriasis among patients with cancer. However, in this study, dysfunctional beliefs about sleep did not mediate the influence of reassurance-seeking on preoccupation with coronavirus. In contrast, reassurance-seeking behavior mediated the influence of dysfunctional beliefs about sleep on preoccupation with coronavirus. Our findings suggest that healthcare professionals should examine sleep problems of patients with cancer to improve not only the sleep problem itself, but also the fear of progression or hypochondriacal worries associated with it.
However, the study has some limitations that need to be considered. First, this survey was conducted among patients with cancer at a single tertiary-level private hospital, limiting the ability to generalize the results of this survey. Second, there is a possibility that an online, anonymous survey could introduce bias. However, to prevent viral transmission in this era of pandemics, online surveys are preferable to face-to-face interviews. Third, the study was conducted two years after the start of the pandemic caused by COVID-19. Thus, the results might have been affected, depending on how participants adjusted to the pandemic situation. Fourth, the majority of participants, about 82.5%, were women. In previous studies [37], it was observed that female participants tended to have higher levels of anxiety toward coronavirus. Our findings were similar, which may be attributed to the predominance of female participants in this sample. Lastly, the sample size is very small, consisting of only 154 patients with cancer, which may limit the generalization of the findings.
Despite its limitations, a strength of this study was that we applied disease-specific rating scales rather than non-specific ones. We used coronavirus-specific rating scales such as the SAVE-6, CRBS, or OCS, to check the feasibility of the cognitive-behavioral model of COVID-related hypochondriasis. Additionally, C-DBAS-14 was applied among patients with cancer.
In conclusion, our findings demonstrate that the OCS is a reliable and valid rating scale to measure preoccupation with coronavirus, and the cognitive-behavioral model of COVID-related hypochondriasis is feasible among patients with cancer. They also revealed that anxiety toward coronavirus, coronavirus reassurance-seeking behavior, and intolerance of uncertainty are positively correlated with preoccupation with coronavirus, and that dysfunctional beliefs about sleep may mediate this relationship. The new model may be used to assess the moderation of indirect effects of anxiety toward coronavirus, reassurance-seeking, and intolerance of uncertainty on preoccupation with coronavirus, using dysfunctional beliefs about sleep.
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