INTRODUCTION
Cholera, a waterborne illness transmitted via the fecal-oral route, poses a significant global health threat. Consuming contaminated food, water, or, less commonly, shellfish can lead to intestinal infection with Vibrio cholerae. Characterized by profuse watery diarrhea, cholera can rapidly progress to dehydration, hypovolemic shock, and, tragically, death within hours of symptom onset [1]. The disease thrives in regions with inadequate access to clean water. Humanitarian crises, marked by population displacement, crowding living conditions, and disrupted water and sanitation systems, amplify the risk of cholera transmission. The World Health Organization (WHO) has reported a concerning increase in cholera cases in recent years. In 2020 alone, 323,369 cases and 857 deaths were documented across 24 countries, underscoring the disease’s severity [2].
Lebanon experienced a cholera outbreak in 2022, originating in Syria and exacerbated by economic hardship and limited access to clean water and sanitation [3,4]. The first case was reported on October 6, 2022 [5], triggering a surge in cases to 5,105 with 23 fatalities by December 9, 2022 [3,5]. Over 50% of cases affected children under 15 years [3]. Hospitals were strained, with 21% of cases requiring hospitalization and 97% presenting with symptoms. A targeted vaccination campaign was initiated on November 4, 2022, in response to the crisis [3].
The COVID-19 pandemic has induced heightened anxiety and obsessive-compulsive behaviors, including excessive hand-washing and sanitizing, in many individuals [6]. Healthcare workers [7] and firefighters [8] are particularly susceptible due to their occupational exposure. Understanding hypochondriasis, or illness anxiety disorder, is crucial in this context. Characterized by an excessive and persistent fear of serious illness despite medical reassurance, hypochondriasis involves misinterpreting normal bodily sensations as signs of disease, leading to distress, disruption, and excessive healthcare seeking.
A cognitive-behavioral perspective is essential for comprehending hypochondriasis [9]. This model emphasizes dysfunctional beliefs about symptoms or illness. Individuals with hypochondriasis may believe that any minor pain indicates a severe disease or that perfect health equates to the absence of bodily sensations. These beliefs amplify attention to normal bodily sensations, leading to their misinterpretation as signs of illness [10]. Several factors contribute to hypochondriasis, including reassurance-seeking behaviors (e.g., frequent temperature checks), excessive internet searches, and underlying anxiety disorders like generalized anxiety disorder. These factors reinforce anxiety and increase the risk of hypochondriasis [10,11]. Hypochondriasis is often linked to insomnia. Insomnia can lead to daytime impairments, including fatigue, mood disturbances, and difficulty concentrating [12]. Anxiety disorders, including hypochondriasis, are significant risk factors for insomnia due to heightened arousal and chronic stress [13].
This study aims to evaluate the applicability of the cognitive-behavioral model to hypochondriasis within the Lebanese population in the context of the cholera outbreak. Additionally, we will investigate the potential influence of insomnia and sleep disturbances on this model.
METHODS
Procedures
Data collection was conducted between January 31 and February 18, 2023, using an online questionnaire distributed via Google Forms. Participants were recruited through a snowball sampling method, sharing the questionnaire link on WhatsApp, Instagram, and Facebook. No financial incentives were offered. Information on participants’ age, sex, education level, marital status, and residence, at the beginning of the questionnaire were collected. The study was approved by the Institutional Review Board of the University of Ulsan (IRB No. 2023R0003), and written informed consent was waived. The study was conducted according to the criteria set by the Declaration of Helsinki.
Measures
Stress and Anxiety to Viral Epidemic-6 items
The Stress and Anxiety to Viral Epidemic-6 items (SAVE-6) is a self-report scale designed to measure anxiety related to viral epidemics in the general population [14,15]. Adapted from the SAVE-9 [15], originally developed for healthcare workers, the SAVE-6 was modified to assess anxiety responses to cholera. Items are rated on a 0–4 Likert scale (0=never, 4=always), with higher scores indicating greater anxiety. This study employed the Arabic version of the SAVE-6, validated among the Lebanese population [16]. The Cronbach’s alpha was 0.810 in our sample.
Obsession with COVID-19 scale
The Obsession with COVID-19 scale (OCS) is a self-report measure assessing persistent preoccupations related to COVID-19 [17]. The OCS consists of four items rated on a five-point Likert scale (0=not at all to 4=nearly every day over the last 2 weeks), with higher scores indicating greater preoccupation. For this study, the OCS was adapted to measure preoccupations with cholera. The Arabic version of the OCS [18] was used, demonstrating good internal consistency, Cronbach’s alpha of 0.733.
Coronavirus Reassurance-Seeking Behaviors Scale
The Coronavirus Reassurance-Seeking Behaviors Scale (CRBS) is a self-report measure assessing reassurance-seeking behaviors related to COVID-19 [19]. The CRBS consists of five items rated on a five-point Likert scale (0=not at all to 4=nearly every day), with higher scores indicating greater reassurance-seeking behaviors. For this study, the CRBS was adapted to measure reassurance-seeking behaviors related to cholera. The Arabic version of the CRBS [18] was used, demonstrating good internal consistency (Cronbach’s alpha=0.803) in our sample.
Insomnia Severity Index
The Insomnia Severity Index (ISI) is a self-report scale assessing insomnia severity [20]. Composed of seven items rated on a 0–4 scale, higher scores indicate more severe insomnia. This study employed the Arabic version of the ISI [21], which demonstrated good internal consistency (Cronbach’s alpha=0.845) in our sample.
Glasgow Sleep Effort Scale
The Glasgow Sleep Effort Scale (GSES) measures sleep effort [22] and consists of seven items rated on a three-point Likert scale, with higher scores indicating greater sleep effort. This study employed the Arabic version of the GSES [23], which demonstrated excellent internal consistency (Cronbach’s alpha=0.862) in our sample.
Patient Health Questionnaire-9 items
The Patient Health Questionnaire-9 items (PHQ-9) is a self-report measure assessing depression severity [24] and consists of nine items rated on a four-point Likert scale, with higher scores indicating more severe depression. The study used the Arabic version of the PHQ-9 [25], which demonstrated excellent internal consistency (Cronbach’s alpha=0.890).
Statistical Analysis
Demographic characteristics were expressed as mean±standard deviation or n (%). Pearson correlation coefficients were calculated to examine correlations among rating scale scores. Linear regression analysis using the enter method was conducted to identify predictors of preoccupation with cholera. Mediation analysis was performed to assess the feasibility of the cholera-related cognitive-behavioral model of hypochondriasis and to explore the influence of sleep effort on this model. Statistical significance was set at p=0.05 (two-tailed). SPSS version 21.0, AMOS version 27 (IBM Corp.), and JASP version 0.14.1.0 software (JASP Team) were used for data analysis.
RESULTS
A total of 472 participants were included in the study. Most participants resided in Beqaa (n=121, 25.6%), followed by Akkar (n=115, 24.4%), North (n=104, 22.0%), Mount Lebanon (n=39, 8.3%), West (n=30, 6.4%), Nabatieh (n=26, 5.5%), Beirut (n=23, 4.9%), Baalbek-hermel (n=13, 2.8%), and Baalbekhermel (n=1, 0.2%). The sample predominantly comprised females (n=363, 76.9%) with a mean age of 25.5 years (standard deviation=7.9, range 18–59). The majority were single (68.6%), followed by married (23.7%), engaged (5.9%), divorced (1.3%), and widowed/widower (0.2%). Educational attainment included university (81.1%), technical school (5.3%), secondary school (10.2%), and primary school (3.4%). A small percentage reported cholera infection (2.5%), while 27.1% had received the cholera vaccine (Table 1).
Table 2 provides the correlations among the study scales. The OCS significantly correlated positively with all other scales (p<0.01), indicating that higher levels of COVID-19-related obsessions were associated with elevated scores on other measures. The CRBS demonstrated a positive correlation with OCS (p<0.01), suggesting a link between obsessions and reassurance-seeking behaviors. The SAVE-6 correlated positively with the OCS, CRBS, PHQ-9, GSES, and ISI (all p<0.01), indicating that higher stress and anxiety levels were associated with elevated scores on these scales. Similar patterns were observed among the PHQ-9, GSES, and ISI.
Table 3 provides the results of a linear regression analysis examining factors influencing preoccupation with cholera, with the OCS score as the dependent variable. The CRBS (β=0.37, p<0.001) and SAVE-6 (β=0.30, p<0.001) significantly predicted the OCS. While the PHQ-9 and GSES showed positive associations with the OCS (β=0.09, p=0.054 and β=0.09, p=0.066, respectively), these relationships were not statistically significant.
To evaluate the cholera-related cognitive-behavioral model of hypochondriasis, mediation analysis was conducted. Results indicated that cholera anxiety directly influenced preoccupation with cholera, and cholera-related reassurance-seeking behavior mediated this relationship (Table 4). A subsequent mediation analysis explored the impact of sleep effort on this model, revealing that sleep effort directly influenced preoccupation with cholera, with cholera anxiety and reassurance-seeking behavior again acting as mediators (Table 5 and Fig. 1).
DISCUSSION
To our knowledge, this study is the first to examine cholera-related hypochondriasis and sleep effort among the Lebanese population. Among 472 participants, significant psychological impacts related to cholera preoccupation were observed. The sample predominantly comprised young (mean age 25.5 years), female (76.9%), and highly educated (81.1% university level) individuals. Linear regression analysis indicated that reassurance-seeking behavior and cholera-related anxiety significantly predicted cholera obsession. Mediation analysis confirmed that both cholera anxiety and reassurance-seeking behavior mediated the relationship between sleep effort and cholera preoccupation. These findings highlight the complex interplay of cognitive and behavioral factors in health-related anxiety, emphasizing the need for targeted mental health interventions.
The current study examined the relationships between scales used to assess cholera-related hypochondriasis, providing valuable insights into underlying mechanisms. Our findings support the proposed model and suggest avenues for future research. Individuals with higher levels of cholera obsession demonstrated a tendency to engage in more frequent reassurance-seeking behaviors, reinforcing the model’s core concept: excessive worry about cholera (obsession) manifests as compulsive reassurance-seeking behavior to alleviate anxiety. Moreover, the findings regarding stress and anxiety related to cholera shed light on potential underlying factors contributing to cholera-related hypochondriasis.
These findings align with the proposed cholera-related hypochondriasis model. The positive correlation between the OCS and CRBS supports the model’s core tenet: cholera anxiety drives reassurance-seeking behavior. Moreover, the positive correlations between the SAVE-6 and other scales suggest that underlying stress and anxiety may contribute to the development and maintenance of this cycle. The current study provides initial support for the cholera-related cognitive-behavioral model of hypochondriasis.
Our findings, discussed in Table 4, demonstrate a clear pathway through which cholera anxiety leads to preoccupation with cholera, mediated by cholera-related reassurance-seeking behavior. The direct effect of cholera anxiety on the preoccupation with cholera shows the model’s core concept: fear of cholera drives excessive focus on potential symptoms. This aligns with the established role of anxiety in hypochondriasis, where general anxiety manifests as a specific illness-related concern. The mediating effect of reassurance-seeking behavior is a key contribution. Individuals experiencing cholera anxiety may engage in repetitive behaviors, such as checking for symptoms or seeking constant reassurance. While initially soothing, these behaviors can paradoxically reinforce the fear and preoccupation with cholera. This cycle of anxiety, reassurance-seeking, and heightened symptom focus strengthens the belief of illness, even in the absence of medical evidence.
In this study, we observed that sleep effort influenced the cholera-related cognitive-behavioral model of hypochondriasis. Lack of sleep is associated with various illnesses, including infections and impaired immunity [26]. A previous study on college students reported that stress and depression mediate the link between poor sleep quality and reduced immunity [27]. Many individuals recognize the correlation between sleep deprivation and immune function, perceiving poor sleep as a risk factor for infections like cholera.
The cognitive model of sleep posits that dysfunctional beliefs about sleep can lead to maladaptive behaviors and thoughts, deteriorating sleeping quality. These manifestations include excessive anxiety, depression, or even obsession with sleep, as evident in high GSES scores. Individuals with poor sleep often overthink insomnia and exert excessive effort to achieve sufficient sleep, paradoxically exacerbating the problem [28]. Such dysfunctional beliefs persist due to health concerns, including the fear that inadequate sleep will compromise the immune system, increasing susceptibility to illness.
Previous studies on patients with cancer [29] and cancer with COVID-19 [30] have shown that sleep disturbances can intensify due to health-related anxieties. Patients often believe that sufficient sleep is crucial for immune function and recovery. A similar phenomenon is likely in cholera outbreaks, where extensive worry and obsessive sleep behaviors can induce psychological distress and arousal. This differs from the reassurance-seeking behavior observed in hypochondriasis, as it primarily focuses on sleep-related concerns rather than the disease itself.
The cognitive-behavioral model of hypochondriasis proposes that individuals with health anxiety hold dysfunctional beliefs about illness, misinterpreting normal sensations as serious diseases [31]. Dysfunctional sleep beliefs contribute to increased sleep effort and insomnia [28]. In the context of cholera, heightened anxiety about contracting the disease may exacerbate sleep disturbances due to the belief that adequate sleep is essential for maintaining immunity and preventing illness.
This study has several limitations. Firstly, the online survey methodology may have overrepresented younger participants, potentially affecting the generalizability of the findings. Secondly, the adaptation of existing scales, originally developed for COVID-19, to assess cholera-related psychological responses may have introduced measurement bias. Additionally, the influence of prior COVID-19 experiences on participants’ responses cannot be entirely ruled out.
In conclusion, this study revealed that the importance of addressing sleep disturbances and implementing cognitive-behavioral interventions to mitigate health anxiety and improve sleep quality during cholera outbreaks. Mental health professionals should consider these factors when developing interventions for vulnerable populations, such as those in Lebanon.
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