Background

Anxiety disorders represent the most prevalent category of psychiatric illnesses globally, with an estimated prevalence of 7.3% and a wide range between 4.8% and 10.9% [1]. Women are disproportionately affected, with adolescent females being up to twice as likely as males to experience anxiety-related conditions [2]. According to the World Health Organization, anxiety disorders ranked among the top six causes of years lived with disability (YLDs) worldwide in 2015 and were even more burdensome in high-income countries [3].

A particular subtype, known as health anxiety (HA), involves persistent worry about having a serious illness, often triggered by normal bodily sensations or minor symptoms [4]. The estimated lifetime prevalence of health anxiety is around 5.7%, with a current prevalence of 3.4%. This form of anxiety is especially relevant among medical students, a population exposed to extensive health-related information and high academic pressure [5]. Commonly referred to as “medical student syndrome” or nosophobia, HA among this group often manifests through exaggerated concern about self-diagnosed illnesses, which may shift based on recent academic or clinical exposure [6].

Health anxiety and hypochondriasis are sometimes used interchangeably, though HA is often considered a milder form, characterized more by anxiety and less by delusional or depressive features [6]. The proliferation of online health resources and symptom-checking tools has further exacerbated HA, with “cyberchondria” now recognized as a factor contributing to its persistence and severity [7].

Several international studies have examined HA among medical students. Research from India reported that nearly one in seven students experienced health anxiety, with preclinical students being the most affected [8]. In the United Arab Emirates, nearly 10% of medical students were found to have HA, often linked to previous experiences with physical or mental illness [9]. In Egypt, a study conducted across ten medical schools revealed that 15.7% of participants experienced clinically significant health anxiety [6]. The prevalence was notably higher among female students (17.5%) and those who reported dissatisfaction with their academic performance (18%) [6]. Further studies noted that while medical students generally demonstrate higher mental health literacy than their non-medical peers, many distressed students still avoid seeking help due to self-reliance and stigma [10,11].

In Saudi Arabia, the prevalence of illness anxiety among adults in Taif was 25.3%, with younger age, female gender, single marital status, and prior hospitalization for cardiac symptoms being significant risk factors [12]. Among Saudi medical students, a recent study identified illness anxiety disorder in 17% of participants, particularly in younger students and those with recent medical visits [13]. National data from 2022 revealed that 12.4% of Saudis were at risk of generalized anxiety disorder, although treatment rates remained low [14]. Although health anxiety may negatively affect student well-being, many studies in this area primarily focus on estimating prevalence and identifying associated factors, with fewer studies assessing quality-of-life outcomes in a structured way.

Therefore, this study aimed to estimate the prevalence of clinically significant health anxiety among Saudi medical students and to identify its sociodemographic and academic predictors across multiple universities. As secondary objectives, we assessed the association between health anxiety and quality of life and explored patterns of disease-related fears reported by students.

Methods

Results

Demographic characteristics and health anxiety prevalence

The study included 650 participants, comprising 455 (70%) without health anxiety and 195 (30%) with health anxiety (Table 1). Age distributions differed significantly between groups (median 23 years [IQR 22–24] vs. 23 years [IQR 21–25], p = 0.04). Academic level showed marked variation (p < 0.001), with Year 2 students having nearly equal proportions of health anxiety (48.5%) and no anxiety (51.5%), while Year 6 students had the lowest prevalence (5.4%). Gender differences were significant (p = 0.004), with 36.3% of females and 25.8% of males experiencing health anxiety. Rural residents had a higher prevalence (43.1% vs. 25.7%, p < 0.001), as did private university students (67.3% vs. 22.9%, p < 0.001). Academic satisfaction was not statistically significant (p = 0.081). Having a family member in the medical field also showed no association (p = 0.9). However, participants with a family psychiatric history (36.1% vs. 25.8%, p = 0.005) or a personal psychiatric history (37.8% vs. 62.2%, p < 0.001) reported significantly higher health anxiety prevalence.

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Table 1. Demographic characteristics and prevalence of health anxiety among participants.

https://doi.org/10.1371/journal.pone.0347337.t001

Demographic characteristics and Quality of Life assessment

Quality of life (QoL) scores demonstrated significant variation across academic levels (p < 0.001), with Year 1 students reporting highest QoL (median 31 [IQR 28−32]) and Year 5 students the lowest (27 [24 -29]) (Table 2). Academic satisfaction showed strong association with QoL (satisfied: 28 [26-32] vs unsatisfied: 26 [24-29], p < 0.001). Participants without psychiatric history reported significantly better QoL (29.5 [27-33]) than those with history (27 [25-30], p < 0.001). Family medical background showed modest QoL association (with medical family: 28 [26-31] vs without: 27 [25-31], p = 0.020). QoL values represent the overall SF-12 composite score (non–norm-based) used for internal comparisons and are not directly comparable to norm-based PCS-12/MCS-12 values.

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Table 2. Quality of life scores across demographic characteristics of participants.

https://doi.org/10.1371/journal.pone.0347337.t002

Multivariable analysis of health anxiety predictors

The logistic regression model revealed several significant predictors (Table 3). Academic year showed nonlinear effects, with Year 2 students having 3.25-fold increased odds (95% CI: 1.53–7.08, p = 0.002) and Year 6 students showing 71.8% reduced odds (AOR = 0.282, 95% CI: 0.0779–0.891, p = 0.031) of health anxiety compared to Year 1. All academic years were included in the regression model; however, Year 4 did not show a statistically significant association and is not presented in Table 3. Male gender demonstrated protective effects (AOR = 0.430, 95% CI: 0.276–0.664, p < 0.001), as did urban residence (AOR = 0.433, 95% CI: 0.272–0.689, p < 0.001). Strikingly, private university attendance conferred 6.14-fold increased odds (95% CI: 3.66–10.5, p < 0.001). Psychiatric history showed strong associations, with family history doubling odds (AOR = 2.11, 95% CI: 1.39–3.21, p < 0.001) and personal history nearly quadrupling odds (AOR = 3.74, 95% CI: 2.27–6.36, p < 0.001).

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Table 3. Multivariable logistic regression analysis of factors associated with Health Anxiety status.

https://doi.org/10.1371/journal.pone.0347337.t003

Model fit indicators suggested that the logistic regression demonstrated adequate fit and good discriminatory power (Hosmer–Lemeshow test: χ² = 6.12, df = 8, p = 0.63; Nagelkerke R² = 0.27; AUC = 0.81, 95% CI 0.76–0.86). No evidence of problematic multicollinearity was detected among predictors (all VIF values < 2.5), suggesting that the regression coefficients were stable and interpretable.

Association between health anxiety and quality of life

A significant negative correlation was observed between health anxiety and quality of life (QoL) scores (r = −0.25, p < 0.001) (Fig 1). As health anxiety levels increased, QoL scores systematically decreased, indicating that higher health-related distress was associated with poorer perceived well-being. This relationship remained robust across the sample, suggesting that health anxiety substantially impacts overall quality of life.

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Fig 1. Scatter plot of health anxiety and quality of life among Saudi undergraduates, highlighting correlation.

The red line represents the fitted linear regression line. A weak negative correlation was observed (r = −0.25, p < 0.001).

https://doi.org/10.1371/journal.pone.0347337.g001

Prevalence of reported mental health conditions The overall prevalence of self-reported psychiatric history (69.2%) was derived from a mandatory yes/no item as shown in Table 1. In contrast, the reporting of specific psychiatric conditions (Fig 2) was based on an optional multiple-response question. Consequently, not all participants who reported a psychiatric history selected a specific condition, and the frequencies of individual disorders should be interpreted as partial representations rather than a complete breakdown. Among the study participants, depression was the most frequently reported mental health condition, 16.3%, followed by stress disorders, 12.8% and sleeping disorders, 12.1%. Social anxiety disorder (8.1%) and generalized anxiety disorder (6.4%) were also notable, while less common conditions included OCD (6.1%) and personality disorders (6.0%). The distribution highlights a predominance of mood and stress-related conditions, with depression alone accounting for nearly one-fifth of all reported mental health concerns.

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Fig 2. Common self-reported psychiatric disorders among Saudi undergraduates.

Participants could select multiple conditions, and responses were optional.

https://doi.org/10.1371/journal.pone.0347337.g002

Disease-related health anxieties and network analysis of disease fear co-occurrenceThe study cohort (N = 650) exhibited a distinct hierarchy of disease-related health anxieties. Malignancy concerns were most prevalent, with 40.9% (n = 266) of participants endorsing cancer as a primary fear. Cardiovascular-related health anxieties followed at 29.7% (n = 193), with diabetes mellitus fears closely trailing at 29.1% (n = 189). Comparable prevalence rates emerged for ophthalmic (27.8%, n = 181) and psychiatric (27.7%, n = 180) health concerns. Secondary analyses revealed substantial anxiety regarding neurological (22.9%), reproductive (22.6%), and cardiovascular-metabolic (hypertension: 18.9%) conditions.Network analysis identified three clinically meaningful fear clusters (Fig 3). First, a somatic threat cluster demonstrated strong co-occurrence between oncological and cardiovascular fears, with 32% joint prevalence. Second, a chronic disease cluster showed significant diabetes-hypertension comorbidity (25% co-occurrence). Third, a neuropsychiatric cluster revealed neural-psychiatric fear associations (18%) that significantly exceeded neural-somatic linkages. The network#39;s global architecture exhibited scale-free properties, with cancer fears serving as the principal hub (betweenness centrality = 0.42).

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Fig 3. Network Analysis of disease fear co-occurrence among respondents.

Node size represents betweenness centrality (higher = more connections); edge thickness indicates pairwise co-occurrence frequency.

https://doi.org/10.1371/journal.pone.0347337.g003

Discussion

This study investigated the prevalence and predictors of health anxiety (HA) among Saudi medical students and examined its association with quality of life (QoL). Our findings reveal that 30% of the participants experienced clinically significant health anxiety, a prevalence notably higher than that reported in comparable studies from Egypt (15.7%), the United Arab Emirates (9.3%), and Pakistan (11.9%) [6,9,18]. This discrepancy may reflect contextual factors such as differences in university environments, academic demands, sociocultural expectations, and access to mental health support.

Consistent with global literature, gender emerged as a significant predictor of health anxiety, with female students reporting substantially higher levels of anxiety than their male counterparts. This trend has been consistently documented in Egypt and Pakistan [6,18], and is often interpreted in light of broader social dynamics. Female students may face unique stressors, including heightened academic expectations, societal pressures, and concerns about future career opportunities, which together may amplify vulnerability to anxiety [19]. Furthermore, epidemiological studies have shown that women are generally more prone to anxiety-related disorders, which may partly explain the pattern observed here [20].

In Saudi Arabia, stigma toward mental health conditions may discourage open reporting of psychological distress, leading some students to frame their anxiety in somatic or health-related terms rather than as a mental health issue [21]. Gender roles and family expectations may also contribute, as female students often face heightened academic and social pressures, in addition to cultural norms that can restrict autonomy and exacerbate internalized worry about health and performance [22,23]. Furthermore, the strong emphasis on family involvement in health decisions may influence patterns of reassurance-seeking and delay independent help-seeking from mental health professionals.

Academic dissatisfaction showed a higher proportion of health anxiety in our sample; however, this association did not reach statistical significance in univariate analysis and was not retained in the multivariable model. Therefore, it cannot be considered an independent predictor in this study. Nevertheless, the observed directional trend is consistent with previous findings from Egypt and other settings [6], suggesting that academic stress may still play a contributory role. The psychological demands of medical education, including continuous exposure to disease-related content and high expectations for academic performance, may heighten students’ sensitivity to bodily symptoms and contribute to maladaptive health-related concerns [24,25]. This context may be particularly relevant during the preclinical years, where theoretical instruction often emphasizes pathology without sufficient clinical reassurance. Supporting this interpretation, our multivariable analysis identified second-year students as being at significantly higher risk of health anxiety, a finding that aligns with prior studies from Pakistan and Egypt [6,18].

One of the most striking findings in this study was the markedly higher likelihood of clinically significant health anxiety among students enrolled in private universities (AOR = 6.14). Although our design does not allow causal inference, the magnitude of this association suggests that institutional context may meaningfully shape students’ psychological experiences. Importantly, this pattern is consistent with prior Saudi evidence showing that private medical university students report significantly higher levels of depression, anxiety, and stress compared with their counterparts in public universities, indicating that elevated distress in private institutions may extend beyond health anxiety specifically [26].

Several plausible mechanisms may explain this association. First, financial pressure is likely a key contributor. Unlike public universities that are typically state-supported for eligible students, private medical education often involves substantial tuition costs and related expenses, which may increase perceived “stakes” of academic performance and intensify stress-related symptom monitoring [27]. Financial strain may also amplify cognitive preoccupation with health as a feared threat to academic continuity and family investment. Second, private institutions may differ in academic structure and competitiveness, including assessment density, grading pressure, or curriculum pacing, which can elevate stress and reinforce repeated exposure to illness-related content without sufficient psychological buffering [28]. Third, differences in availability and accessibility of student well-being infrastructure, including counseling capacity, confidentiality perceptions, and proactive screening programs, could influence whether students receive early support or continue reassurance-seeking and symptom checking, which are core maintaining behaviors in health anxiety [29].

Beyond structural explanations, cultural and social-contextual factors may also shape how health anxiety emerges and is expressed in different institutional environments. For example, private university students may experience stronger family expectations linked to financial investment, which may increase fear of failure and heighten attention to bodily sensations during periods of stress [30]. Peer norms may also differ: if private-university culture fosters more competitive academic comparison or less open discussion of mental health concerns, students may be more likely to internalize distress and express it through somatic or illness-related worry rather than seeking psychological support [31]. Additionally, religious coping practices and spiritual interpretations of illness may influence health-related fears in nuanced ways, either buffering anxiety through meaning-making and acceptance, or potentially increasing vigilance if illness is perceived as a serious threat requiring constant monitoring [32]. Although these mechanisms were not directly measured in our study, they represent plausible and testable pathways that could help explain why private university enrollment showed such a large association with health anxiety [33].

Future research should therefore adopt mixed-methods approaches to clarify institutional drivers and contextual mechanisms. Quantitative studies could compare private and public institutions using objective indicators such as tuition burden, scholarship availability, academic workload intensity, and student-to-counselor ratios, while qualitative interviews or focus groups could explore perceived academic pressure, family expectations, stigma, coping strategies, and help-seeking behavior [34]. Such work would guide targeted and institution-specific interventions, particularly within private universities, where preventive mental health screening, early psychoeducation about health anxiety, and accessible confidential counseling may be especially impactful [34].

Personal and family psychiatric history emerged as powerful predictors. Students with a personal history of mental health conditions were nearly four times more likely to experience HA, while those with a family history had double the odds. These findings align with established evidence suggesting that individuals with prior psychological vulnerability or familial predisposition are at increased risk for health-focused anxieties [35].

Importantly, the study also established a significant inverse relationship between health anxiety and quality of life. Students with elevated HA scores consistently reported lower QoL, particularly in mental health domains. This correlation supports findings from previous regional studies and highlights the broader implications of HA for students’ well-being [6]. The impact of persistent health concerns can extend beyond psychological distress, affecting sleep, concentration, academic performance, and social engagement [36]. Over time, this can erode resilience and reduce functioning across multiple life domains.

Although the correlation between health anxiety and quality of life was modest, this finding indicates that even relatively small increases in health anxiety can meaningfully interfere with students’ daily functioning, academic performance, and well-being. Similarly, the observed odds ratios, while statistically robust, also highlight clinically relevant disparities; for example, male students were substantially less likely to report high health anxiety, suggesting that female students may represent a particularly vulnerable subgroup in need of targeted support [37,38]. Taken together, these results underscore that even small-to-moderate associations can carry important implications for medical education, as they translate into tangible challenges for student support services and mental health policy within universities.

These findings suggest that early interventions, such as resilience training, peer support initiatives, and routine mental health screening, may help mitigate the real-world impact of health anxiety on student wellbeing and academic performance [39,40].

An additional contribution of this study lies in its exploration of students’ self-reported disease-related fears. Cancer, cardiovascular disease, and diabetes emerged as the most common sources of health anxiety, forming identifiable clusters of concern. The network analysis further revealed patterns of fear co-occurrence, with oncological concerns serving as a central hub. This may reflect the heightened awareness of these conditions among medical students, potentially exacerbated by their academic exposure to severe clinical cases without balanced reassurance or contextualization [41,42].

Taken together, these findings point to the hidden psychological costs of medical education in Saudi Arabia. Health anxiety appears to be a prevalent and multifaceted issue, shaped by individual, academic, and environmental factors. Its association with diminished quality of life signals the need for early interventions. Medical curricula may benefit from integrating wellness education, resilience training, and accessible psychological services, particularly for students in the early years of training and those with identifiable risk factors [43].

Given the markedly higher odds of health anxiety among students enrolled in private universities (AOR = 6.14), Year 2 students (AOR = 3.25), and female students (AOR = 2.33), institutions should adopt targeted and measurable strategies rather than generalized wellness messaging. First, to reduce tuition-related stress, private universities may implement structured financial protection mechanisms, such as need-based emergency mental health grants and temporary tuition deferral or installment plans for students who screen positive for significant distress, with transparent eligibility criteria (e.g., confirmed high SHAI score and documented functional impairment). Second, medical colleges should strengthen counseling access by adopting minimum service standards, including a minimum counselor-to-student ratio of 1:1,500 with an institutional target of 1:1,000, aligned with commonly referenced university mental health staffing benchmarks [44]. Institutions may also define service performance indicators such as same-day walk-in triage, guaranteed follow-up appointments within ≤7–14 days, and confidential referral pathways for students with psychiatric history [45].

Third, academic interventions should be risk-stratified: because Year 2 students represented the highest-risk academic group in our model, schools should implement mandatory peer/near-peer mentoring programs during Year 2 [46], pairing junior students with trained senior mentors, and integrating structured sessions addressing coping with symptom-focused anxiety, academic stress, and health-related reassurance-seeking behaviors; peer mentoring models in medical education have shown academic and psychosocial benefits and are feasible within resource-limited settings. Fourth, universities should introduce routine screening protocols using validated instruments such as the SHAI (as applied in this study) during predictable high-stress periods (e.g., midterms and final examination months), with standardized follow-up for high-risk subgroups (females, rural residents, private university students, and those with personal or family psychiatric history) [45]. Finally, to ensure accountability, universities should evaluate these interventions using measurable outcomes such as reductions in SHAI scores over time, counseling utilization rates, wait-time indicators, academic retention, and student-reported quality of life.

Conclusion

This study highlights a high prevalence of health anxiety among Saudi medical students, affecting nearly one-third of participants, with significant associations observed between health anxiety and lower quality of life. Key predictors included female gender, rural residence, private university enrollment, and personal or family psychiatric history. These findings underscore the psychological burden faced by medical students and the need for targeted mental health support within academic institutions. Addressing health anxiety early through structured interventions, improved access to counseling services, and wellness programs may help mitigate its negative impact on students’ well-being, academic performance, and long-term professional development.

Acknowledgments

Our heartfelt thanks also go to p-value research hub platform. Their training empowered researchers, starting from beginner levels, to undertake this study and become authors. We are immensely grateful for the support provided by this remarkable organization.