Diagnostic uncertainty and addiction-like reassurance seeking in patients with pulmonary nodules: a cross-sectional study

Low-dose computed tomography (LDCT) screening and the increasing use of chest computed tomography (CT) have created a large population of patients living with indeterminate pulmonary nodules (PNs) and diagnostic uncertainty. This study aimed to develop and psychometrically evaluate the Pulmonary Nodule Addiction-like Behavior Scale (PNABS) and to identify addiction-like reassurance-seeking profiles among patients with PNs across diagnostic conditions.

This cross-sectional study enrolled 1,800 adults with CT-detected PNs (4-30 mm) at a tertiary thoracic surgery center from January 2021 to December 2024. The cohort was a mixed tertiary-care PN cohort and was not restricted to either lung cancer screening-detected nodules or incidental PNs. Participants were sampled across three diagnostic conditions: preoperative without definitive pathology (n=900), postoperative benign/pre-invasive pathology (n=450), and postoperative malignant pathology (n=450). PNABS psychometric properties were evaluated using split-half exploratory and confirmatory factor analyses. Latent profile analysis identified behavioral profiles, network analysis examined conditional associations with psychological and functional measures, and hierarchical regression tested whether PNABS explained 6-month health care utilization beyond generalized anxiety.

Among 1,800 participants {mean [standard deviation (SD)] age, 55.21 (11.37) years; 920 (51.1%) female}, the PNABS showed excellent internal consistency and factorial validity [Cronbach alpha =0.947; confirmatory factor analysis (CFA): Comparative Fit Index (CFI) =0.962, Tucker-Lewis Index (TLI) =0.958, Root Mean Square Error of Approximation (RMSEA) =0.042]. Latent profile analysis supported three profiles: Adaptive, Distressed, and Compulsive. The Compulsive profile was most common in the preoperative group (47.0%) and least common in the postoperative benign/pre-invasive group (6.2%). Participants in the Compulsive profile (536/1,800, 29.8%) accounted for 41.9% of CT examinations and 43.6% of outpatient visits over 6 months. Adding PNABS to GAD-7 increased explained variance for CT examinations, outpatient visits, and excessive provider switching by 0.239-0.253 (all P<0.001).

Among patients with PNs, diagnostic uncertainty was associated with difficult-to-regulate reassurance seeking, particularly before definitive pathology was available. The PNABS demonstrated promising psychometric performance and captured behaviorally specific variance in health care utilization beyond general anxiety symptoms. Surveillance pathways may benefit from early communication support and behavioral triage for patients showing compulsive reassurance-seeking patterns.