What treatment options are available for a patient with severe health anxiety?

Treatment for Severe Health Anxiety

Cognitive-behavioral therapy specifically adapted for health anxiety (CBT-HA) is the most effective first-line treatment for severe health anxiety, with sustained benefits lasting up to 8 years and superior outcomes compared to standard care. 1, 2

First-Line Treatment Approach

Cognitive-Behavioral Therapy for Health Anxiety (CBT-HA)

CBT-HA should be the primary treatment, delivered in 4-10 sessions (mean of 6 sessions) by a trained health professional or psychologist. 1

• Treatment produces significant improvement in health anxiety scores by 3 months that is maintained over 5-8 years without loss of efficacy. 1, 2
• Nurse therapists achieve superior outcomes compared to other mental health professionals, making them ideal practitioners for this condition. 1, 2
• CBT-HA also significantly reduces generalized anxiety and depression symptoms more effectively than standard care. 1, 2

Key CBT-HA Components

The therapy should include: 3, 4

• Education about anxiety and the relationship between bodily sensations and health anxiety
• Cognitive restructuring to challenge catastrophic health-related thoughts and beliefs
• Behavioral experiments to test feared health outcomes
• Gradual exposure to health-related triggers (medical information, bodily sensations)
• Reduction of reassurance-seeking and body checking behaviors

Pharmacotherapy Considerations

When to Add Medication

If CBT-HA is unavailable, not preferred by the patient, or symptoms are severe with comorbid depression, add an SSRI as first-line pharmacotherapy. 3, 4

First-Line Medications

Start with sertraline 25-50 mg daily or escitalopram 5-10 mg daily. 4, 5

• Titrate sertraline by 25-50 mg increments every 1-2 weeks to target dose of 50-200 mg/day 5
• Titrate escitalopram by 5-10 mg increments to target dose of 10-20 mg/day 4
• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 4

Alternative First-Line Options

Venlafaxine extended-release 75-225 mg/day or duloxetine 60-120 mg/day are effective alternatives if SSRIs fail or are not tolerated. 4

• Monitor blood pressure with venlafaxine due to risk of sustained hypertension 4
• Start duloxetine at 30 mg daily for one week to minimize nausea, then increase to 60 mg 4

Combined Treatment Strategy

For patients with severe health anxiety or comorbid depression, combination treatment (CBT-HA + SSRI) provides superior outcomes compared to either treatment alone. 3, 4

• When both depression and anxiety symptoms are present, prioritize treatment of depressive symptoms first, or use a unified protocol combining CBT treatments for both conditions. 3

Monitoring and Treatment Adjustment

Regular Assessment Schedule

Assess treatment response using standardized instruments at baseline, 4 weeks, 8 weeks, and end of treatment. 3

• For pharmacotherapy, regularly assess symptom relief, side effects, and patient satisfaction at 4 and 8 weeks 3
• Monitor closely for suicidal thinking, especially in the first months and following dose adjustments (pooled risk 1% vs 0.2% placebo) 4

When Treatment Fails

If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen: 3

• Switch to a different SSRI (e.g., sertraline to escitalopram)
• Add CBT-HA if using medication alone
• Add medication if using CBT-HA alone
• Consider switching from group to individual therapy if applicable

Patient-Specific Factors Predicting Success

Patients with mild personality disturbance and higher dependence levels achieve the best outcomes with CBT-HA. 1

• Gastroenterology and cardiology patients show the greatest CBT gains 1, 2
• Presence of personality abnormality is not a contraindication to successful treatment 1

Adjunctive Strategies

Provide psychoeducation to family members about health anxiety symptoms and treatment. 4

Teach specific anxiety management techniques: 4

• Breathing techniques and progressive muscle relaxation
• Grounding strategies and sensory techniques
• Mindfulness practices
• Regular cardiovascular exercise

Treatment Duration

Continue medication for 6-12 months after remission to prevent relapse. 6

• Discontinue medications gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 4
• CBT-HA benefits are maintained long-term without need for ongoing therapy sessions 1, 2

Critical Warnings

Avoid benzodiazepines as first-line treatment due to risks of dependence, tolerance, and withdrawal; reserve only for short-term use. 4

Standard care without specific treatment for health anxiety promotes depression over time, making active intervention essential. 2

Do not start SSRIs within 14 days of MAOI discontinuation, and allow 14 days after stopping SSRIs before starting MAOIs. 5