Rates and correlates of illness anxiety disorder among health college students: A cross-sectional study

Abstract

BACKGROUND

Illness anxiety disorder (IAD) is characterized by persistent fear of developing a serious illness. Despite the absence of significant medical findings, individuals with this condition often misinterpret normal bodily sensations or minor symptoms as indications of severe disease.

AIM

To estimate and compare the prevalence of IAD among health college students at King Saud University.

METHODS

This observational cross-sectional study utilized data collected through an online, self-administered questionnaire; an Arabic version of the short health anxiety inventory (SHAI) was employed. A total of 325 students from health colleges at King Saud University in Riyadh were included in the study.

RESULTS

The overall prevalence of IAD (defined as a SHAI score of ≥ 17) was 28.9%, with the highest prevalence observed among students from the College of Nursing. IAD was significantly associated with sex, college affiliation, a history of psychiatric disorders, and exposure to abuse or neglect.

CONCLUSION

A notable prevalence of IAD was noted among health college students, highlighting the need for increased awareness and targeted interventions. The implementation of comprehensive counseling and support services is recommended to effectively address this issue.

Key Words: Illness anxiety disorder; Health anxiety; Hypochondriasis; Health colleges; Saudi Arabia

Core Tip: Illness anxiety disorder was identified in 28.9% of health college students at King Saud University, indicating a notable psychological concern within this group. Higher levels were found among female students, those enrolled in nursing programs, and individuals with prior psychiatric conditions or experiences of abuse or neglect. No meaningful associations were observed with age, academic level, or personal and family medical history. These results highlight the importance of focused mental health screening and support strategies for vulnerable student populations in healthcare education settings.

INTRODUCTION

Illness anxiety disorder (IAD), also referred to as hypochondria, medical student syndrome, or health anxiety, is characterized by an excessive and persistent fear of developing a serious illness. Even in the absence of significant medical findings, individuals with IAD often misinterpret normal bodily sensations or minor symptoms as indications of severe disease[1]. This condition is marked by an intense preoccupation with having or developing a serious, undiagnosed medical disorder. Physical symptoms are either minimal or entirely absent. Illness anxiety is a specific form of anxiety disorder focused on health-related concerns.

It is typically chronic and episodic, with a tendency for relapse, and most commonly manifests in early to middle adulthood. Episodes are often triggered by awareness of illness in others or exposure to medical reports[2]. Medical knowledge can underscore the fine line between health and disease, prompting individuals to reassess previously overlooked symptoms in light of new information[3].

Clinical and economic impact of IAD

Individuals with IAD may experience significant distress and functional impairment, even when their level of illness anxiety is moderate. They often engage in repeated medical consultations, request additional diagnostic tests, search online medical resources, and seek reassurance regarding bodily sensations that have been assessed and deemed benign. The emotional, cognitive, and behavioral manifestations of IAD can profoundly disrupt social, occupational, and family functioning. Moreover, the condition can impose substantial medical and economic burdens[4].

Prevalence among health science students

Health science students—including those pursuing degrees in clinical medicine, dentistry, public health, nursing, and pharmacology—are at increased risk of mental distress due to the competitive nature of their academic environments, which generates academic and social pressures[5]. This population may also experience illness-related anxiety related to the diseases they study, a phenomenon often referred to as medical student syndrome[6].

A 2013 study conducted at King Saud University in Saudi Arabia reported that 3.4% of medical students met criteria for IAD. This study further reported that the prevalence rates of IAD were 2.9% among male students and 3.8% in female students[7]. Subgroup analysis indicated that the prevalence of illness-related fears was notably higher among pre-clinical students (21.1%) compared with students in advanced academic years (14%), with a significant difference[8]. A 2019 study conducted in China among health science students reported that 28.0% exhibited symptoms of IAD[9]. More recently, a 2023 study conducted in Riyadh, Saudi Arabia, using the 18-item short health anxiety inventory (SHAI), found that 22.3% of medical students were affected by the disorder[10].

Study rationale and hypothesis

No previous studies have comprehensively included all health colleges at King Saud University—including the College of Medicine and Surgery, Dentistry, Pharmacy, Nursing, Emergency Medical Services, and Applied Medical Sciences[11]. Screening for IAD remains essential to determine whether symptoms reach the clinical threshold, particularly as the prevalence varies across geographical regions and over time[12].

Therefore, this study aimed to assess the prevalence of IAD among students enrolled in the health colleges of King Saud University. It also aimed to investigate whether the prevalence of IAD varies according to the field of study within the medical and health sciences and whether the disorder presents differently among students based on their chosen specialization[13].

IAD is hypothesized to occur more frequently in women compared with men[7]. The prevalence of IAD is also expected to be higher among medical students compared with students from other health-related colleges[8]. Additionally, younger students are considered more susceptible to developing IAD[14-16].

MATERIALS AND METHODS

This observational cross-sectional study was performed at King Saud University, Riyadh, Saudi Arabia, between February and March 2024, involving 325 health college students. Data were collected using a self-administered online survey, and participants were recruited through a convenience sampling method.

Sample size calculation

The required sample size was calculated using the standard formula for estimating the proportions in a population: n = Z² × P × (1 - P)/D² where Z = 1.96 (corresponding to a 95% confidence level), P = 20% (expected prevalence, 0.2), and D = 5% (margin of error, 0.05). Substituting these values yielded: n = [1.96² × 0.2 × (1 - 0.2)]/0.05² = 246. To account for an anticipated 20% non-response rate, 49 additional participants were included, resulting in a final sample size of 295 participants.

A pilot study was conducted with 10 participants to evaluate the questionnaire and identify any potential linguistic or comprehension issues. Written informed consent was obtained from all participants, and no personal identifying information was collected. Data were used solely for scientific purposes.

Inclusion and exclusion criteria

Participants included undergraduate students enrolled in health colleges at King Saud University, regardless of gender. Preparatory year students, non-health college students, and individuals not affiliated with King Saud University were excluded.

Data collection and study instruments

Data were collected using an online questionnaire administered via Google Forms. The questionnaire included baseline demographic information (e.g., sex, age, academic year, college, personal and family history of mental health disorders, personal and family histories of medical conditions) alongside the SHAI.

The SHAI, a self-report questionnaire developed by Salkovskis et al[17] to assess health anxiety in both clinical and non-clinical populations, was used to evaluate participants' health anxiety. The Arabic version, translated and adapted by Alshayea[18], was employed in this study. In the Arabic version, item 14 was omitted because it was considered inapplicable to the Saudi population, resulting in a modified 17-item SHAI with a maximum possible score of 51. As no validated cutoff currently exists for this modified version, a proportionally adjusted cutoff score of ≥ 17 was applied based on the validated Arabic SHAI cutoff of 18 for the original 18-item questionnaire (maximum score = 54)[19]. This adjusted cutoff was used for research purposes and should be interpreted with caution because it has not been clinically validated for the modified 17-item Arabic SHAI (SHAI-17).

Each item included four statements representing varying symptom levels, and participants were instructed to select the statement that best described their experiences over the preceding 6 months. Responses were scored on a 4-point Likert scale ranging from 0 (no symptoms) to 3 (severe symptoms). Consistent with the original scale, the items were grouped into two subscales: (1) Illness likelihood (IL), comprising the first 14 items with scores ranging from 0 to 42; and (2) Negative consequences (NCs), comprising the remaining four items with scores ranging from 0 to 12. Higher scores indicated greater levels of the assessed construct[17]. In Alshayea’s study[18], exploratory and confirmatory factor analyses supported a two-factor structure: IL (13 items) and NCs (four items). This structure demonstrated invariance across genders and good internal consistency, with a Cronbach’s α of 0.85 for the total scale, 0.83 for IL, and 0.77 for NCs.

Ethical considerations

Informed consent was obtained electronically from all participants prior to completing the questionnaire. The purpose of the study was clearly explained, and participants were informed of their right to withdraw at any time without any obligation to the research team. To minimize response bias and protect privacy, no names or personal identifiers were collected. The participants were also informed that no incentives or rewards would be provided for their participation.

This study was approved by the Institutional Review Board of King Saud University on January 30, 2024 (Approval No. E-24-8502). Ethical approval was ensured that the study adhered to established ethical standards and safeguarded the rights and well-being of all participants.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences version 23. Categorical variables were summarized as n (%), and continuous variables were presented as means, standard deviations, minimum values, and maximum values.

The psychometric properties of the modified SHAI-17 were evaluated in the study sample. Internal consistency was assessed using Cronbach's α coefficient. Construct validity was examined using exploratory factor analysis with principal component analysis and promax rotation. The suitability of the data for factor analysis was evaluated using the Kaiser-Meyer-Olkin measure of sampling adequacy and Bartlett's test of sphericity. A two-factor solution was specified a priori based on the conceptual structure of the previously validated Arabic SHAI.

Associations between categorical variables were assessed using the χ² test. Differences in continuous variables between two groups were evaluated using the independent-samples t-test, whereas means across three or more groups were compared using one-way analysis of variance (ANOVA), followed by Tukey's post hoc test when appropriate.

Factors associated with IAD were initially evaluated using univariate Logistic regression analysis. Variables with a P value < 0.05 in the univariate analysis were subsequently entered into a multivariable Logistic regression model to identify independent predictors. Odds ratios (ORs) with corresponding 95% confidence intervals were reported.

All questionnaire items were mandatory; therefore, no missing data were present, and all 325 completed questionnaires were included in the final analysis. A two-sided P value < 0.05 was considered statistically significant.

RESULTS

A total of 325 participants were included in this study. The sociodemographic and academic characteristics of the participants are summarized in Table 1. The participants’ age ranged from 19 years to 25 years. In terms of sex distribution, 207 participants (63.7%) were women. In terms of academic affiliation, 72 participants (22.2%) were enrolled in the College of Medicine, whereas 86 participants (26.5%) were from the College of Applied Health Sciences. Additionally, 104 participants (32%) were in their third academic year. The total number of students invited to participate was not recorded at the time of survey distribution. Consequently, the overall response rate could not be calculated, limiting the assessment of potential selection bias and representativeness of the study sample.

Table 1 Sociodemographic and academic characteristics of the study participants (n = 325).

Demographic characteristics	n	%
Age in year	21.06 ± 1.4
Minimum	19
Maximum	25
Sex
Female	207	63.70
Male	118	36.30
College
College of Applied Health Sciences	86	26.50
College of Medicine	72	22.20
College of Pharmacy	65	20.00
College of Nursing	47	14.50
College of Dentistry	35	10.80
College of Emergency Medical Services	20	6.20
Academic year
First year	50	15.40
Second year	68	20.90
Third year	104	32.00
Fourth year	67	20.60
Fifth year	20	6.20
Intern	16	4.90

Personal and family medical history

Table 2 summarizes the personal and family histories of psychiatric and chronic diseases among the participants. A total of 50 participants (15.4%) reported a previous diagnosis of a psychiatric disorder. The most frequently reported conditions were depression (22 participants, 44%), anxiety (21 participants, 42%), and generalized anxiety disorder (11 participants, 22%). With regard to chronic diseases, 36 participants (11.1%) reported currently having a chronic condition, with asthma (27.78%) and diabetes mellitus (11.11%) being the most common. Additionally, 26 participants (8%) reported having been diagnosed with a chronic disease during childhood, with asthma being the most frequently reported condition (18 participants, 69.23%). Furthermore, 80 participants (24.6%) indicated having a family member previously diagnosed with a psychiatric illness. Conversely, 137 participants (42.2%) reported having a family member with a chronic or serious disease.

Table 2 Personal and family histories of psychiatric and chronic diseases (n = 325).

Question	n	%
Have you ever been diagnosed with a psychiatric disorder?
Yes	50	15.4
No	275	84.6
If you have been previously diagnosed with a psychiatric disorder, what was it? (n = 50)
Depression	22	44.00
Anxiety	21	42.00
Generalized anxiety disorder	11	22.00
Panic attacks	4	8.00
Social anxiety disorder	4	8.00
Obsessive compulsive disorder	3	6.00
Attention deficit hyperactivity disorder	2	4.00
Bipolar disorder	1	2.00
Other	5	10.00
Are you currently diagnosed with any chronic disease?
Yes	36	11.1
No	289	88.9
If you are currently diagnosed with a chronic disease, what is it? (n = 36)
Asthma	10	27.78
Diabetes mellitus	4	11.11
Irritable bowel syndrome	3	8.33
Polycystic ovarian syndrome	2	5.56
Hypothyroidism	2	5.56
Hypertension	1	2.78
Psoriasis	1	2.78
Sinusitis	1	2.78
Other	11	30.56
Have you ever been diagnosed with a chronic disease when you were a child?
Yes	26	8
No	299	92
If you have been diagnosed with a chronic disease in your childhood, what was it? (n = 26)
Asthma	18	69.23
Diabetes	3	11.54
Hypothyroidism	2	7.69
Other	3	11.54
Have any of your family members been previously diagnosed with a psychiatric disorder?
Yes	80	24.60
No	245	75.40
Does any of your family members have a chronic or serious chronic disease?
Yes	137	42.2
No	188	57.8

Multiple responses were permitted for psychiatric diagnoses; therefore, percentages do not sum to 100%.

Prevalence of IAD

The prevalence of IAD based on the SHAI is presented in Table 3. Among the participants, 94 (28.9%) were identified as having IAD. SHAI scores ranged from 0 to 39, with a mean score of 13.57 ± 6.73.

Table 3 Prevalence of illness anxiety disorder based on the short health anxiety inventory (n = 325).

Question	n	%
The short health anxiety inventory score
Minimum	0
Maximum	39
Mean	13.57
SD	6.73
The short health anxiety inventory score
Have illness anxiety disorder	94	28.9
Do not have illness anxiety disorder	231	71.1

Factors associated with IAD scores

Table 4 presents the factors associated with IAD scores. Female participants had significantly higher IAD scores compared with male participants (P = 0.041), with mean scores of 14.14 ± 6.58 and 12.56 ± 6.88, respectively. College affiliation was also significantly associated with IAD scores (P = 0.05). Specifically, participants from the College of Dentistry had the lowest IAD scores, whereas those from the College of Nursing had the highest scores. Post hoc analysis using the Tukey’s test indicated that participants from the College of Nursing had significantly higher IAD scores compared with those from the College of Dentistry (P < 0.05).

Table 4 Factors associated with the score of illness anxiety disorder.

Factor	Illness anxiety disorder score		P value
	Mean	SD
Sex			0.041a
Male	12.56	6.88
Female	14.14	6.58
College			0.05a
College of Nursing	15.72	7.29
College of Applied Health Sciences	14.13	6.81
College of Emergent Medical Services	13.65	5.04
College of Pharmacy	13.60	6.85
College of Medicine	12.53	6.77
College of Dentistry	11.34	5.54
Academic year			0.087
First year	15.50	7.61
Second year	12.81	5.54
Third year	13.55	7.03
Fourth year	13.48	6.54
Fifth year	14.50	7.56
Intern	10.13	4.77
Have you ever been diagnosed with a psychiatric disorder?			0.005a
Yes	16	7.84
No	13.13	6.42
Are you currently diagnosed with any chronic disease?			0.555
Yes	14.19	7.73
No	13.49	6.60
Have you ever been diagnosed with a chronic disease when you were a child?			0.376
Yes	14.69	8.13
No	13.47	6.60
Have you ever experienced abuse or neglect during childhood?			0.032a
Sexual abuse	16.75	8.85
Physical abuse	16.04	5.38
Neglect	15	5.27
Verbal abuse	13.55	7.49
None	12.84	6.44
Have any of your family members been diagnosed with psychiatric illness?			0.077
Yes	14.73	7.42
No	13.19	6.46
Do any of your family members have a chronic or serious chronic disease?			0.689
Yes	13.74	6.40
No	13.44	6.97

^aP ≤ 0.05.

Participants with a history of psychiatric illness had significantly higher IAD scores compared with those without such a history (P = 0.005), with mean scores of 16 ± 7.84 and 13.13 ± 6.42, respectively. A history of abuse or neglect was also significantly associated with IAD scores (P = 0.032), with individuals reporting a history of sexual abuse exhibiting the highest scores.

The analysis revealed a weak negative correlation between age and IAD scores (correlation coefficient = -0.09); however, this relationship was not statistically significant (P = 0.104). Other variables—including academic year, current chronic disease, childhood chronic disease, family history of psychiatric illness, and family history of chronic or serious disease—were not significantly associated with IAD scores.

Univariate analysis (Table 5) identified nursing-college enrollment, childhood sexual abuse, and a family history of psychiatric illness as significantly associated with IAD. After adjustment (Table 6), these factors remained independent predictors, with adjusted ORs of 3.50, 4.39, and 1.93, respectively. No significant associations were observed for the remaining sociodemographic or clinical variables.

Table 5 Univariate Logistic regression for factors associated with illness anxiety disorder.

		Odds ratio	95%CI		P value
			Lower	Upper
Gender	Male	0.93	0.52	1.68	0.816
	Female1	1.00
Age		0.89	0.72	1.10	0.266
College	College of Nursery	4.00	1.20	13.33	0.024a
	College of Emergent Medical Services	1.94	0.43	8.78	0.391
	College of Pharmacy	1.75	0.52	5.92	0.364
	College of Medicine	1.40	0.41	4.75	0.592
	College of Applied Health Sciences	1.38	0.42	4.57	0.598
	College of Dentistry1	1.00
Academic year	First year	5.83	0.70	48.42	0.102
	Second year	2.89	0.35	24.23	0.327
	Third year	2.73	0.34	22.12	0.347
	Fourth year	3.61	0.44	29.87	0.234
	Fifth year	5.00	0.52	48.07	0.163
	Intern1	1.00
Have you ever been diagnosed with psychiatric disorder?	Yes	1.49	0.73	3.07	0.275
	No1	1.00
Are you currently suffering from any chronic disease?	Yes	0.87	0.35	2.20	0.769
	No1	1.00
Have you ever been diagnosed with a chronic disease when you were a child?	Yes	1.06	0.38	2.92	0.916
	No1	1.00
Have you ever been mistreated/abused in your childhood?	Verbal abuse	1.98	0.98	4.03	0.058
	Physical abuse	2.21	0.85	5.70	0.103
	Sexual abuse	5.15	1.76	15.01	0.003a
	Neglect	2.54	0.84	7.73	0.099
	None1	1.00
Have any of your family members been previously diagnosed with psychiatric illness?	Yes	1.88	1.03	3.44	0.041a
	No1	1.00
Do any of your family members have a chronic or serious chronic disease?	Yes	0.90	0.51	1.59	0.708
	No1	1.00

^aP ≤ 0.05.

¹Used as a reference.

95%CI: 95% confidence interval.

Table 6 Multivariable Logistic regression for factors associated with illness anxiety disorder.

		Odds ratio	95%CI		P value
			Lower	Upper
College	College of Nursery	3.50	1.01	12.18	0.049a
	College of Emergent Medical Services	1.82	0.39	8.57	0.447
	College of Pharmacy	1.60	0.46	5.54	0.458
	College of Medicine	1.33	0.38	4.65	0.651
	College of Applied Health Sciences	1.05	0.31	3.57	0.943
	College of Dentistry1	1.00
Have you been mistreated/abused in your childhood?	Verbal abuse	2.08	1.00	4.34	0.051
	Physical abuse	1.98	0.74	5.31	0.176
	Sexual abuse	4.39	1.40	13.77	0.011a
	Neglect	2.16	0.68	6.89	0.194
	None1	1.00
Have any of your family members been previously diagnosed with psychiatric illness?	Yes	1.93	1.01	3.69	0.048a
	No1	1.00

^aP ≤ 0.05.

¹Used as a reference.

95%CI: 95% confidence interval.

Reliably and factor analysis

The psychometric properties of the SHAI-17 were evaluated in the current sample. The scale demonstrated good internal consistency, with a Cronbach's α of 0.835 for the total scale. The Health Anxiety Subscale (13 items) showed good internal consistency (Cronbach's α = 0.824), and the NCs of Becoming Ill Subscale (4 items) demonstrated acceptable internal consistency (Cronbach's α = 0.746). Construct validity was assessed using exploratory factor analysis with principal component analysis and promax rotation. A two-factor solution was specified based on the previously validated Arabic SHAI. The data were suitable for factor analysis, as indicated by a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.864 and a significant Bartlett's test of sphericity [χ² (136) = 1519.37, P < 0.001]. The two-factor solution explained 40.87% of the total variance, with the first and second factors accounting for 29.09% and 11.78% of the variance, respectively. Although most items loaded meaningfully on one of the two factors, the rotated pattern matrix showed that several items exhibited cross-loadings and that the pattern of item loadings was not entirely identical to that reported in the original Arabic validation study. Overall, these findings indicate that the modified Arabic SHAI-17 demonstrated satisfactory internal consistency and acceptable construct validity in the current sample.

DISCUSSION

This study estimated and compared the prevalence of IAD among students in the health colleges at King Saud University using the SHAI. IAD is a mental disorder characterized by a persistent preoccupation with having or developing a serious, undiagnosed medical condition[2].

Based on the SHAI, the prevalence of IAD among the participants was 28.9%, whereas 71.1% did not exhibit illness anxiety. The prevalence observed in this study was higher than that reported in previously published studies. For example, a study conducted at Taif University reported an IAD prevalence of 16.2% among medical and non-medical students[8]. Similarly, a study in Greece found a prevalence of 18.1% among health science students[20].

Gender and discipline variations

Of the 325 students, 63.7% were women, and 36.3% were men. Female students in the health colleges exhibited significantly higher levels of unrealistic fears about illnesses compared with their male counterparts (P = 0.041), consistent with our hypothesis. Similar findings were reported in another study at King Saud University, which found a notably higher prevalence of IAD among female students compared with male counterparts[21]. By contrast, a study conducted in China revealed no significant sex-based differences[9].

Interestingly, students from the College of Nursing had the highest IAD scores. These findings are consistent with a study conducted exclusively among the female students at Princess Nourah Bint Abdulrahman University in Riyadh[22]. However, students from the College of Dentistry had the lowest IAD scores. A study conducted at a Greek university, however, reported no significant variation in SHAI scores among participants from various health science disciplines[20].

Age, academic year, and psychological factors

This study found no significant differences in IAD scores across academic years or age groups. However, a previous study conducted among medical students has reported a negative association between age and IAD[14]. A recent study indicated that fourth-year nursing students had higher SHAI scores compared with younger students[22]. Similarly, another study using the Illness Attitude Scales found a relationship between age and the tendency to develop IAD among undergraduate students in medicine and dentistry[23].

Participants with a prior psychiatric diagnosis exhibited significantly higher IAD scores compared with those without such a diagnosis (P = 0.005). Additionally, a history of abuse or neglect was significantly associated with IAD scores (P = 0.032), particularly among individuals with a history of sexual abuse, who exhibited the highest scores. These findings are supported by an outpatient study reporting psychiatric comorbidities in 71.4% of IAD patients—25% with depression and 28.6% with anxiety—and noting that one-third of patients had histories of childhood abuse (physical, emotional, or sexual)[4].

Limitations

Several limitations should be acknowledged. First, the study was conducted at a single university in Riyadh, potentially limiting the variability of responses; therefore, the findings cannot be generalized to students in health colleges at other universities. Second, the response rate among male participants was lower than that of female participants, potentially introducing a slight response bias. Finally, variations in response rates across the various colleges may have contributed to minor inconsistencies in the findings. Furthermore, the cross-sectional design precludes establishing temporal relationships or causal inferences between the identified associated factors and IAD. Therefore, the observed associations should be interpreted as associations rather than causal relationships. Additionally, all data were collected through a self-administered online questionnaire with convenience sampling, which may have introduced response and reporting bias. Because all questionnaire items were mandatory, participation and response patterns may also have been influenced. Furthermore, IAD was identified using the SHAI-17 for research purposes and was not confirmed through clinical diagnostic interviews. Lastly, unmodeled potential confounders, including current stressors, academic performance, use of internet-based health information, and levels of social support, were not controlled in the present analysis and may have influenced SHAI scores. We recommend including these factors in future studies.

CONCLUSION

The overall prevalence of IAD was 28.9% and was significantly associated with sex, college, a history of psychiatric disorders, and experiences of abuse or neglect. These findings should be interpreted within the context of health college students and may not be generalizable to the broader university student population or the general population. Further research should include students from healthcare colleges across different regions of Saudi Arabia. It should also ensure consistent response rates across colleges and maintain a balanced male-to-female ratio. Given the relatively high prevalence of IAD observed herein, future research should also evaluate the effectiveness of targeted screening programs and brief interventions, including psychoeducational and cognitive behavioral therapy-informed approaches, to reduce illness anxiety symptoms and improve mental health outcomes among health college students.

ACKNOWLEDGEMENTS

We would like to thank Dr. Ahmad Alshayea for granting permission to use the translated SHAI-17 scale in this study.