What is the recommended management approach for hypochondriac disorder?

Management of Hypochondriasis (Health Anxiety Disorder)

Cognitive-behavioral therapy (CBT) is the first-line treatment for hypochondriasis, with both cognitive therapy and exposure therapy demonstrating high efficacy, and SSRIs should be considered as adjunctive pharmacotherapy when psychological treatment alone is insufficient. 1, 2

Establishing the Therapeutic Foundation

The cornerstone of managing hypochondriasis is establishing a strong therapeutic relationship with the patient, as this disorder often presents significant engagement challenges. 3 This relationship should be built on:

• Validation of the patient's distress while reframing the problem from "finding a disease" to "managing health anxiety" 4
• Regular, scheduled appointments rather than as-needed visits to reduce emergency presentations and provide structure 2
• Collaborative goal-setting focused on functional improvement and quality of life rather than symptom elimination 3

First-Line Psychological Treatment

CBT should be offered as the primary treatment modality, with strong evidence supporting its efficacy (effect sizes of 1.01-1.24). 1 The treatment can be delivered in two equally effective formats:

Cognitive Therapy Approach

• Target catastrophizing and misinterpretation of bodily sensations through cognitive restructuring 1
• Challenge dysfunctional beliefs about health, illness, and the meaning of physical symptoms 4, 5
• Address health-related safety behaviors and reassurance-seeking patterns 1

Exposure Therapy Approach

• Systematic exposure to health-related fears without engaging in safety behaviors 1
• Reduction of body checking, reassurance-seeking, and medical consultations through behavioral experiments 1
• Particularly effective for reducing safety behaviors compared to cognitive therapy alone 1

Important clinical note: Both approaches effectively change dysfunctional cognitions, meaning cognitive interventions are not strictly necessary for cognitive change—exposure alone can modify health-related beliefs. 1 This is a critical finding that challenges traditional assumptions about requiring cognitive work.

Treatment Format Options

• Individual CBT has the strongest evidence base 2
• Group CBT may also be useful and is more cost-effective, though evidence is somewhat weaker 2
• Treatment duration: Typically 12-16 sessions with assessments at mid-treatment to adjust approach 5

Pharmacological Management

SSRIs represent the most promising pharmacological option when psychological treatment is insufficient, refused, or needs augmentation. 2

Prescribing Approach

• Start with low doses and titrate slowly ("start low, go slow"), particularly when comorbidities exist 6, 7
• First-line SSRI options include fluoxetine, sertraline, or paroxetine 2
• Monitor for concurrent mood and anxiety disorders, which occur in over 50% of patients and may respond to pharmacotherapy 3, 2

Critical Caveat

The evidence for pharmacotherapy in primary hypochondriasis is limited—no controlled trials exist, only case series and open-label studies. 2 Therefore, medication should not be used as monotherapy when CBT is available and feasible.

Assessment for Psychiatric Comorbidity

Screen systematically for conditions requiring specialist referral:

• Depression and anxiety disorders (present in at least 50% of cases) 3
• Suicidal ideation or hopelessness requiring urgent psychiatric intervention 6
• Substance use disorders, particularly in younger patients 6, 7
• Quality of life impairment and avoidance behaviors affecting daily functioning 6

Alternative Psychological Approaches

When CBT is not available or acceptable:

• Behavioral stress management shows efficacy comparable to CBT at 12-month follow-up, though slower initial response 5
• Supportive psychotherapy may benefit certain patients but lacks standardized protocols and controlled evidence 2
• Psychoanalytic therapy has insufficient evidence to recommend routinely 2

Treatment Outcomes and Follow-Up

• Both CT and ET maintain significant improvements at 1-year follow-up 1
• Regular monitoring of emotions, thinking, behavior, and functioning facilitates early intervention for relapse 6
• Coordinate care between primary care, mental health specialists, and other involved providers to prevent fragmented treatment 6

Common Pitfalls to Avoid

• Endless investigation of new symptoms: Recognize that polysymptomatic presentation suggests somatization rather than organic disease requiring further workup 8
• Focusing solely on physical symptoms: This reinforces the patient's disease conviction rather than addressing the underlying anxiety 3
• Dismissing the patient's concerns: This ruptures the therapeutic alliance and increases healthcare utilization 2
• Delaying mental health referral: Moderate to severe symptoms warrant specialist involvement early 6