How to manage hypochondriasis?

Management of Hypochondriasis

Cognitive-behavioral therapy (CBT) is the first-line treatment for hypochondriasis, with demonstrated efficacy in reducing health anxiety and preoccupation with illness, and should be initiated as soon as the diagnosis is established. 1, 2

Initial Assessment and Diagnosis

• Screen for underlying anxiety disorders, particularly generalized anxiety disorder, as hypochondriasis frequently presents with somatic complaints and health anxiety that may mask an anxiety disorder 3
• Use the GAD-7 scale (score ≥9 indicates positive screen) to identify generalized anxiety disorder in patients presenting with apparent hypochondriasis 3
• Recognize that at least half of patients with functional disorders like IBS demonstrate hypochondriacal features, and identifying this pattern helps avoid endless investigation of new symptoms 3
• Assess for comorbid depression, as hypochondriacal patients have higher rates of mood disorders, and this affects treatment planning 3, 2

Establishing the Therapeutic Relationship

• The cornerstone of management is establishing a good therapeutic relationship where the physician recognizes that patients have psychological and interpersonal reasons for feeling symptomatic 4, 5
• Stop trying to cure the patient's symptoms; instead, shift the goal to assisting the patient in coping with symptoms 5
• Avoid focusing on specific somatic symptoms, as this reinforces the hypochondriacal pattern and leads to inappropriate investigation or treatment 3

Cognitive-Behavioral Therapy (Primary Treatment)

• Individual CBT is the most effective treatment, with controlled studies demonstrating superiority over behavioral stress management and waitlist controls 1, 2
• CBT should target four factors that amplify somatic distress: (1) attention paid to symptoms, (2) catastrophic thoughts about symptoms, (3) context in which symptoms are experienced, and (4) mood states 6, 5
• Group CBT may also be useful as an alternative when individual therapy is not available, though evidence is stronger for individual treatment 2
• Treatment effects are maintained at 12-month follow-up, indicating durable benefit 1

Pharmacological Treatment

• Selective serotonin reuptake inhibitors (SSRIs) show promise for hypochondriasis, though evidence is limited by lack of controlled trials 2
• Consider SSRIs particularly when comorbid depression or anxiety disorders are present 2
• Pharmacotherapy should not be first-line given the stronger evidence for CBT, but can be used adjunctively or when psychotherapy is unavailable 2, 4

Management of Comorbid Conditions

• Systematically screen for fibromyalgia, chronic fatigue syndrome, and other functional somatic syndromes, as these overlap substantially with hypochondriacal presentations 3
• Recognize that patients with multiple somatic complaints report higher levels of health anxiety, neuroticism, and reduced quality of life 3
• Address underlying mood disorders with appropriate treatment, as antidepressants may improve both depression and hypochondriacal symptoms 3

Avoiding Common Pitfalls

• Do not order extensive investigations for each new symptom, as this reinforces illness beliefs and increases healthcare utilization 3
• Avoid referrals to multiple specialists, which fragment care and validate the patient's conviction of serious disease 3
• Recognize that hypochondriasis and somatization indicate that focusing on specific bowel or other somatic symptoms will not be profitable 3
• Be aware that supportive or psychoanalytical psychotherapy may help certain patients, but lack of standardized treatments makes them less preferable options 2

Structured Treatment Approach

• Begin with psychoeducation about the cognitive-behavioral model of health anxiety, explaining how attention, thoughts, and behaviors maintain symptoms 6
• Use behavioral experiments to test catastrophic health beliefs and reduce checking behaviors 6
• Teach patients to moderate their attention to bodily sensations through mindfulness and distraction techniques 5
• Address safety behaviors (e.g., excessive doctor visits, body checking, reassurance seeking) that maintain the disorder 6