How to manage a patient with hypochondriasis?

Management of Hypochondriasis

Cognitive-behavioral therapy (CBT) is the first-line treatment for patients with hypochondriasis, as it has been shown in controlled studies to be more effective than other interventions for reducing health anxiety and improving quality of life. 1

Understanding Hypochondriasis

Hypochondriasis (now often referred to as illness anxiety disorder or somatic symptom disorder) is characterized by:

• Excessive preoccupation with having or acquiring a serious illness
• Persistent fear despite medical reassurance
• Significant distress and functional impairment
• Misinterpretation of normal bodily sensations as signs of serious disease

The prevalence in primary care settings ranges from 0.8% to 4.5% 2, making it a relatively common condition that clinicians need to address effectively.

Diagnostic Approach

When evaluating a patient with suspected hypochondriasis:

• Obtain thorough collateral information from caregivers, as patients may minimize or deny problems 3
• Assess for changes in emotions, thinking, physical state, and functioning 3
• Rule out medical conditions that could explain symptoms
• Evaluate for comorbid psychiatric conditions (depression, anxiety disorders, other somatoform disorders) 2

Treatment Strategy

1. Establish a Therapeutic Relationship

• Acknowledge the patient's distress and symptoms as real
• Avoid dismissive language or suggesting symptoms are "all in their head"
• Schedule regular, time-limited appointments rather than as-needed visits
• Maintain a consistent approach across all healthcare providers

2. First-Line Treatment: Cognitive-Behavioral Therapy

CBT has the strongest evidence base for hypochondriasis 2, 1:

• Helps patients identify and challenge catastrophic misinterpretations of bodily sensations
• Reduces symptom checking and reassurance-seeking behaviors
• Addresses avoidance behaviors related to health anxiety
• Provides alternative explanations for physical symptoms
• Can be delivered in individual or group formats

In a randomized controlled trial, CBT was more effective than behavioral stress management for reducing hypochondriacal symptoms 1.

3. Pharmacological Management

Consider medication when:

• CBT is unavailable or ineffective
• Severe anxiety or depression is present
• Patient prefers medication (though only 4% of patients with hypochondriasis prefer medication as first-line treatment) 4

Selective serotonin reuptake inhibitors (SSRIs) show the most promise for treating hypochondriasis 2, though evidence is limited compared to CBT.

4. Addressing Reassurance-Seeking Behavior

• Provide clear, consistent information without excessive reassurance
• Explain that repeated medical tests and reassurance can perpetuate anxiety
• Establish boundaries around emergency contacts and unscheduled visits
• Focus on "relational" aspects of reassurance within a therapeutic framework 5

5. Managing Comorbid Conditions

Hypochondriasis frequently co-occurs with other conditions:

• Assess and treat comorbid anxiety disorders
• Screen for depression and provide appropriate treatment
• Consider the relationship with other somatoform disorders

Practical Management Tips

• Avoid excessive medical testing - Unnecessary tests can reinforce health anxiety
• Provide predictable routine - Schedule regular follow-ups rather than as-needed visits
• Use simple language - Explain medical information clearly without technical jargon 3
• Involve family/caregivers - Educate them about not reinforcing health anxiety 3
• Address specific fears - Target the patient's particular health concerns directly
• Develop safety plans - Create strategies for managing anxiety between appointments 3

Long-Term Management

• Schedule regular follow-up visits (every 3-6 months)
• Monitor for symptom improvement using standardized measures
• Assess for emergence of new somatic concerns
• Provide booster sessions of CBT if symptoms recur
• Recognize that some degree of health anxiety may persist long-term

Pitfalls to Avoid

1. Dismissing symptoms - This damages the therapeutic relationship
2. Excessive reassurance - Can paradoxically increase anxiety over time
3. Unnecessary referrals - May reinforce belief in serious illness
4. Inconsistent approaches - All providers should maintain a unified strategy
5. Focusing only on physical symptoms - Address psychological aspects as well

Remember that patients with hypochondriasis experience genuine distress and deserve compassionate, evidence-based care. With appropriate treatment, particularly CBT, many patients can experience significant improvement in both symptoms and quality of life.