What is the recommended treatment for Illness Anxiety Disorder?

Treatment of Illness Anxiety Disorder

Cognitive Behavioral Therapy (CBT) specifically designed for health anxiety is the recommended first-line treatment for Illness Anxiety Disorder, with SSRIs (particularly sertraline or escitalopram) as the primary pharmacotherapy option when medication is needed. 1, 2

Psychotherapy as Primary Treatment

CBT targeting health anxiety should be the initial treatment approach for most patients with Illness Anxiety Disorder, as it directly addresses the core psychopathology of worry cycles and reassurance-seeking behaviors. 2

CBT Implementation Strategy

• Individual CBT sessions are preferred over group therapy due to superior clinical effectiveness in anxiety disorders. 3, 1
• The therapy should specifically target the cycle of health worry and reassurance-seeking that characterizes Illness Anxiety Disorder, rather than focusing on somatic symptom relief. 2
• If face-to-face CBT is not feasible or desired by the patient, self-help CBT with professional support is a viable alternative. 3, 1
• Treatment should integrate CBT principles into all patient interactions, using health concerns as opportunities to reinforce therapeutic skills rather than providing reassurance. 4

Key CBT Components

• Address the patient's anxiety about illness with an empathic, curious, and nonjudgmental stance to maintain therapeutic alliance. 2
• Train the patient to recognize and interrupt reassurance-seeking behaviors across all healthcare interactions. 4
• Minimize medical work-up and reactive responses to health concerns, instead redirecting to coping skills. 4

Pharmacotherapy Options

First-Line Medications

SSRIs are the primary pharmacological treatment, with sertraline and escitalopram preferred due to their favorable safety profiles and effectiveness. 1, 5, 6

• Sertraline or escitalopram should be initiated as first-choice SSRIs for their lower potential for drug interactions and superior tolerability. 1
• SNRIs (particularly venlafaxine extended-release) are equally effective alternatives to SSRIs and can be used as first-line treatment. 1, 5, 6
• Fluvoxamine is approved for anxiety disorders but may have more side effects than sertraline or escitalopram. 1

Medications to Avoid

• Paroxetine and fluoxetine should be avoided, especially in older adults, due to higher rates of adverse effects. 1
• Benzodiazepines are not recommended for routine use in Illness Anxiety Disorder, as they do not address the core psychopathology and carry risks of dependence. 5
• If benzodiazepines are absolutely necessary for very short-term use, use lower doses with shorter half-lives. 1

Treatment Duration

Medications should be continued for at least 6-12 months after symptom remission for a first episode. 1, 5

• For recurrent or chronic presentations, longer-term or indefinite treatment may be necessary. 1, 7
• Stopping medication prematurely increases relapse risk within the first year of treatment initiation. 7

Integrated Treatment Approach

Coordination of Care

Collaboration between all medical providers is essential to prevent the pitfalls of excessive testing and medical treatment that reinforce health anxiety. 2

• Consolidate care with a single provider team when possible to ensure consistent communication. 4
• Train all staff and family members to respond to health concerns in a therapeutically consistent manner. 4
• Use a standardized communication approach that minimizes reassurance while maintaining empathy. 4

Managing Medical Concerns

• Respond to health concerns by reinforcing psychotherapy principles rather than ordering tests or providing reassurance. 4
• Simplify medication regimens when possible, avoiding reactive medication changes in response to anxiety. 4
• Address legitimate medical conditions (e.g., hypertension, vitamin deficiencies) within the therapeutic framework. 4

Treatment Algorithm

1. Start with individual CBT specifically designed for health anxiety as the primary intervention. 3, 1, 2
2. Add an SSRI (sertraline or escitalopram) or SNRI (venlafaxine) if CBT alone is insufficient or if patient preference/severity warrants combined treatment. 1, 5, 6
3. If the first medication fails, switch to another SSRI or SNRI rather than adding additional agents. 1
4. Continue treatment for at least 6-12 months after remission, with longer duration for recurrent cases. 1, 5
5. Maintain coordinated care across all providers to prevent reassurance-seeking and excessive medical utilization. 4, 2

Common Pitfalls to Avoid

• Providing repeated reassurance, which temporarily reduces anxiety but reinforces the disorder long-term. 4, 2
• Ordering excessive medical tests in response to patient anxiety rather than clinical indication. 2
• Allowing fragmented care across multiple providers who inadvertently enable reassurance-seeking. 4, 2
• Discontinuing effective treatment prematurely before adequate consolidation of gains. 5, 7