**1. Introduction**

In late 2019, a respiratory syndrome called coronavirus disease (COVID-19) began to spread, posing a mortal threat to the health of people around the globe [1,2]. Generally, COVID-19 has an incubation period of 1–14 days, and its symptoms include mild to severe fever, cough, dyspnea, and pneumonia [3,4]. The fatality rate is between 1% and 2%. The World Health Organization classified COVID-19 as a pandemic in March 2020. Due to a sharp increase in the number of confirmed cases and deaths, many governments around the world declared a state of emergency and advised people to practice social distancing to minimize contact with others, including self-isolating at home [1,2,5].

Beyond the impact on physical health, ongoing uncertainty related to the pandemic and the dramatic changes in behavior required by social distancing efforts may uniquely and profoundly impact mental health, and these problems may be more likely among individuals with certain psychological conditions [6–8]. Specifically, pre-existing health anxiety (although recently changed to "illness anxiety" in the fifth edition of the Diagnostic and

**Citation:** Sica, C.; Caudek, C.; Cerea, S.; Colpizzi, I.; Caruso, M.; Giulini, P.; Bottesi, G. Health Anxiety Predicts the Perceived Dangerousness of COVID-19 over and above Intrusive Illness-Related Thoughts, Contamination Symptoms, and State and Trait Negative Affect. *Int. J. Environ. Res. Public Health* **2021**, *18*, 1933. https://doi.org/10.3390/ ijerph18041933

Academic Editor: Paolo Roma Received: 10 January 2021 Accepted: 12 February 2021 Published: 17 February 2021

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Statistical Manual of Mental Disorders [9], "health anxiety" is still in common use by mental health researchers and clinicians and is the term used in the ubiquitous cognitive behavioral model of health anxiety (for a discussion, see Bailer et al. [10])) may represent an important vulnerability factor contributing to heightened concerns about the COVID-19 pandemic. The essential feature of health anxiety, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) [9], is the presence of worries, concerns, or fears of having or acquiring a serious physical disease or other health-related issues [11,12]. Individuals with health anxiety are extremely preoccupied with bodily sensations and functions and with anything that may appear to be a sign of a pathological condition. They may excessively scrutinize medical and health information and frequently look up symptoms and diseases on the Internet (known as cyberchondria) [13,14]. This behavior may lead them to misinterpret trivial symptoms as reflecting serious ailments [15,16].

The aims of the current study were (1) to investigate how health anxiety, relative to other clinical problems, is associated with perceptions of COVID-19 dangerousness and (2) to determine whether the onset of COVID-19 has influenced the prevalence of health anxiety.

#### *1.1. Health Anxiety and Epidemics*

Few studies have been carried out to evaluate the associations between health anxiety and the fear of infection during an epidemic. This is a surprising limitation, given that one might expect the general tendency toward health-related worries to be associated with heightened concern in the context of disease outbreaks [15]. Blakey and Abramowitz [17] investigated psychological predictors (including health anxiety) of virus-related anxiety in 216 adults during the 2015–2016 Zika outbreak. Overestimations of the likelihood of contamination and greater factual knowledge about Zika emerged as the only variables predicting Zika-related anxiety. Wheaton and colleagues [18] examined the psychological processes associated with swine-flu-related anxiety in 315 college students during the H1N1 influenza pandemic of 2009–2010. Regression analysis indicated that health anxiety symptoms were the third significant predictor (*β* = 0.21) of swine-flu-related anxiety, after contamination fears and disgust sensitivity (both *βs* = 0.28).

More recently, Jungmann and Witthöft [19] conducted an online survey with 1615 individuals to investigate the roles of health anxiety, cyberchondria, and coping in COVID-19 related anxiety. Health anxiety showed positive relationships with virus anxiety (*r* = 0.34), distress caused by Internet research (*r* = 0.48), and maladaptive emotion regulation (*r* = 0.17). In addition, individuals with heightened health anxiety reported an increase in virusrelated anxiety in recent months, according to a retrospective report. Importantly, however, findings from this last study do not allow for firm conclusions to be drawn about the specificity of the relationship between health anxiety and COVID-19-related anxiety, since other potentially relevant psychological variables—such as depression, contamination compulsions, and general anxiety—were not taken into account.

Similarly, Cannito and colleagues [20] found that during the national lockdown in Italy, health anxiety predicted attentional bias toward virus-related objects [21]. However, as in the study above, it was not possible to rule out the influence of general psychological distress or other clinical variables. Indeed, attentional bias toward threats is a common phenomenon among anxious populations [22], so it is unclear if health anxiety plays a specific role in disease-related cognitive processing.
