What medication can be given to a patient with hypochondriasis (hypochondria) to alleviate associated anxiety symptoms?

Medication for Hypochondriasis

For a patient with hypochondriasis, start fluoxetine at 20 mg daily and titrate to 60-80 mg daily over 8-12 weeks, as this selective serotonin reuptake inhibitor (SSRI) has demonstrated efficacy in reducing hypochondriacal concerns even in patients without major depression. 1

Evidence-Based Pharmacological Approach

First-Line Treatment: SSRIs

• Fluoxetine is the most strongly supported medication for primary hypochondriasis, with open-label trials showing 10 of 16 patients (62.5%) achieving marked improvement after 12 weeks of treatment 1

• Higher doses are required for hypochondriasis compared to depression—fluoxetine should be titrated to 60-80 mg daily, similar to dosing strategies used in obsessive-compulsive disorder 1

• Treatment duration must be adequate: a minimum 12-week trial at therapeutic doses is necessary before concluding treatment failure 1

• Sertraline represents an alternative SSRI option with minimal drug interactions and a favorable side effect profile, though specific efficacy data for hypochondriasis is limited 2

Why SSRIs Work for Hypochondriasis

• The pharmacologic response pattern in hypochondriasis mirrors that of obsessive-compulsive disorder rather than depression—requiring higher doses and longer treatment duration 3

• Traditional tricyclic antidepressants (TCAs) are not effective for general hypochondriasis, unlike their efficacy in depression, further supporting the use of selective serotonin reuptake inhibitors 3

• The intrusive, repetitive nature of disease-related thoughts in hypochondriasis shares phenomenological similarities with OCD, explaining the preferential response to serotonergic agents 3

Clinical Algorithm for Medication Selection

Step 1: Assess for comorbid major depression

• If major depression is present, treat the depression first as this often improves hypochondriacal symptoms 4, 5
• If no major depression, proceed with SSRI specifically for hypochondriasis 1

Step 2: Initiate fluoxetine

• Start at 20 mg daily 6
• Increase to 40 mg after 2-4 weeks if tolerated 6
• Target dose: 60-80 mg daily by week 6-8 1

Step 3: Monitor response

• Assess at 4,8, and 12 weeks using standardized measures of health anxiety 1
• Look for reduction in disease preoccupation, decreased checking behaviors, and improved functioning 1

Step 4: If inadequate response after 12 weeks

• Consider switching to another SSRI (sertraline 100-200 mg daily) 2
• Evaluate for unrecognized comorbid anxiety or depressive disorders 4

Critical Monitoring and Safety Considerations

• Monitor for suicidal ideation, particularly in the first few months of treatment or with dose changes, as all antidepressants carry this risk in younger adults 2

• Watch for serotonin syndrome if combining with other serotonergic agents—symptoms include agitation, confusion, rapid heartbeat, muscle rigidity, and hyperthermia 2

• Avoid abrupt discontinuation—taper gradually to prevent withdrawal symptoms including anxiety, irritability, dizziness, and electric shock-like sensations 2

• Patients may initially experience increased anxiety or behavioral activation in the first 1-2 weeks; reassure them this typically resolves with continued treatment 2

Common Pitfalls to Avoid

• Using antidepressant doses instead of higher SSRI doses—this is the most common error, as hypochondriasis requires 60-80 mg fluoxetine equivalent, not the 20-40 mg used for depression 1

• Discontinuing treatment prematurely—response may not be evident until 8-12 weeks at therapeutic doses 1

• Prescribing benzodiazepines as primary treatment—while they may provide short-term anxiety relief, they do not address the core hypochondriacal beliefs and carry dependence risks 4

• Failing to combine with cognitive-behavioral therapy—medication alone is less effective than combined treatment, as CBT addresses the cognitive distortions underlying disease conviction 4, 7

Adjunctive Non-Pharmacological Treatment

• Cognitive-behavioral therapy is the most evidence-based psychotherapy for hypochondriasis and should be offered alongside medication 4, 7

• CBT targets the misinterpretation of bodily sensations and the selective attention to symptoms that perpetuates the hypochondriacal cycle 7

• Individual CBT has stronger evidence than group therapy, though both formats show benefit 4